Citation Nr: 21076438 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 18-47 856 DATE: December 23, 2021 REMANDED Entitlement to service connection for dermatophytosis is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from January 2003 to September 2003, to include service in Afghanistan. He also had service in the Army National Guard, to include a period of active duty for training from May 1999 to September 1999, and a period of active duty for special work from September 2005 to December 2005. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. The issue on appeal was most recently before the Board in July 2021, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. After taking further action, the AOJ confirmed and continued the prior denial and returned the case to the Board. See September 2021 supplemental statement of the case (SSOC). Entitlement to service connection for dermatophytosis is remanded. The Veteran seeks to establish service connection for dermatophytosis, claimed as athlete's foot. He contends that the condition had its onset during active service in New Orleans, Louisiana, in the aftermath of Hurricane Katrina. In the July 2021 remand, the Board requested that the AOJ obtain a medical nexus opinion regarding the Veteran's dermatophytosis. The Board directed that the examiner was to specifically consider and discuss the Veteran's contention that he developed sores and pustules on the bottom of his feet during and since service. The Board instructed the examiner that the Veteran was competent to report observable symptoms and indicated that a fully-explained rationale for the requested opinion should be provided. In a September 2021 opinion, an examiner opined that it was less likely than not that the Veteran's claimed condition was caused by an in-service event, injury, or illness. The examiner stated that the report of sores and pustules on the bottom of the Veteran's feet during service in 2005 was not consistent with the diagnosis of dermatophytosis or athlete's foot/tinea pedis. The examiner noted that the records through 2004 were negative for a foot or dermatologic condition, and that the Veteran's claims were not substantiated by his service treatment records. The examiner further observed that, even if the Veteran's statements were conceded, the condition that he described would not be consistent with athlete's foot, which seldom involves pustules and sores. The examiner explained, in addition, that common symptoms of athlete's foot were erythema, flaky skin, and pruritus. The examiner noted that an individual could cause secondary sores from scratching, but that the condition itself did not usually cause complaints of blistering and pustules. The examiner concluded that while such symptoms could have been related to direct and continued immersion of the Veteran's feet after Hurricane Katrina, there appeared to be no residuals. The examiner further concluded that it would be highly unlikely that an individual would have endured the condition for the claimed timeframe without care for a chronic condition involving pustules and sores. Thus, the September 2021 examiner discussed the Veteran's claims involving pustules and sores on his feet. At the same time, the examiner observed that an individual could cause secondary sores from scratching and he relied, in part, on the lack of treatment for the condition. In a January 2017 statement, the Veteran reported that his feet were constantly itching and burning, and that he scratched his feet to the point that they sometimes bled. In a May 2017 statement, he reported that he "didn't even have enough [sense] or knowledge about [athlete's foot] to know it was a medical condition." He claimed that he did not go to a doctor to seek treatment for his conditions because he was unable to afford to do so. He indicated he had scars on his feet from constantly scratching them, and that he sometimes had to sleep with toilet tissue between his feet to stop blood from getting on his bed sheets. The Board finds that the examiner failed to address all of the relevant evidence of record in providing a rationale for the nexus opinion offered. Specifically, the examiner did not consider the Veteran's lay statements to the effect that he scratched his feet to the point that they sometimes bled and did not seek treatment because he was unaware that what he had was a medical condition and he was unable to afford care. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). Additional development is required. This matter is REMANDED for the following action: 1. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 2. After the foregoing development has been completed, arrange to have the Veteran scheduled for a VA skin disorders examination. The examiner should review the record. All indicated tests should be conducted and the results reported. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner should identify any skin disabilities of the feet that the Veteran has had at any time since January 2017 (when he filed his claim for service connection), to include any dermatophytosis/athlete's foot. Then, with respect to each such disability, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the disability had its onset in, or is otherwise attributable to, the Veteran's periods of active service, to include as due to prolonged periods where his feet were wet during his active duty service following Hurricane Katrina. In doing so, the clinician should specifically discuss the Veteran's statements regarding instances where his feet itched, and he scratched them to the point that they bled. The clinician should also discuss the Veteran's report that he did not previously know that the condition was something that he could/should seek formal treatment for, and that he could not afford treatment in any event. The clinician is advised that the Veteran is competent to report symptoms, treatment, and injuries observable to a layperson. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The clinician is also reminded that the absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Thus, the clinician is to consider the totality of the record, and not just the absence of clinical treatment, in weighing the Veteran's statements asserting symptomatology. Stated another way, the examiner may not rely on the absence of corroborating evidence in the STRs in reaching his or her conclusion. However, the examiner may consider whether the Veteran's post-service statements with respect to in-service and post-service symptomatology are consistent or inconsistent with other entries or medical facts as set out in the STRs and elsewhere in the record. A complete medical rationale for all opinions expressed must be provided. If the examiner cannot provide an opinion without resort to speculation, he or she must provide an explanation as why that is so. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of the need for additional information, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to a particular question. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue on appeal should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran and his representative should be issued a SSOC. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Ferguson, 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.