Citation Nr: 21076517 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 14-22 180 DATE: December 27, 2021 ORDER Service connection for a skin disorder, to include as secondary to herbicide exposure, is denied. FINDING OF FACT There is no probative medical evidence that indicates that any of the Veteran's current skin disorder diagnoses, to include stasis dermatitis, xerosis (dry skin), and eczema, were incurred in service, to include as due to herbicide exposure. CONCLUSION OF LAW The criteria to establish service connection for a skin disorder have not been satisfied. 38 U.S.C. §§1110, 5107 (b) (West 2014); 38C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from August 1969 to February 1972. The procedural history of this claim is outlined in the June 2019, May 2020, March 2021, and August 2021 Board of Veterans' Appeals (Board) and Court of Appeals for Veterans Claims (CAVC or Court) remands and decisions. Most recently the case was remanded for an addendum medical opinion. All actions ordered by the remand have been accomplished. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Any veteran who, during active military service, served in the Republic of Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicide agents. 38C.F.R. §§3.307, 3.309. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. Military personnel records indicate the Veteran served in the Republic of Vietnam from May 1970 through April 1971 and thus his exposure to herbicide is presumed. The list of diseases that are deemed associated with herbicide exposure includes chloracne, but does not include acne, dermatitis, or eczema. The Veteran's current skin diagnoses do not qualify for presumptive service connection. However, where the evidence does not warrant presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The Board must analyze the competency and credibility of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept it means that the person or person who makes the statement is qualified by training, education, an occupation, personal experience, or other reason to make the statement. Credibility is a factual determination it involves deciding whether the testimony or other evidence is believable, and the determination is made after the evidence has been found competent. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran's disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104 (a). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for a skin disorder, to include as secondary to herbicide exposure November 2019 private treatment records indicate a dermatologist diagnosed the Veteran with stasis dermatitis, xerosis (dry skin) and eczema. The Veteran contends that the skin disorder was incurred in service due to herbicide exposure. The Veteran's November 1968 report of medical history at induction indicates he denied skin diseases. His clinical skin evaluation was normal. In October 1971 the Veteran complained of a skin disorder. He was assessed with acne and prescribed surgical soap twice daily. In October 1971 the Veteran again complained of a skin disorder. The symptom was again assessed as acne, and in November 1971 he was prescribed antibiotics. In December 1971 his prescription was renewed, and in January 1972 his prescription dosage was reduced. His January 1972 clinical skin evaluation prior to discharge was normal. The Veteran served in Vietnam from May 1970 to April 1971. At a June 2011 VA medical examination, the Veteran reported recurrent itching since service, without associated rash or skin eruptions. He denied obtaining a skin disorder diagnosis from a physician since discharge. The examiner noted that the Veteran did not demonstrate any current skin complaints, to include itching, or evidence of any rash or eruptions. The examiner stated that the objective data did not support a definitive diagnosis of a current skin disorder. At the October 2018 Board hearing, the Veteran testified that he had recurrent severe itching since service. He reported applying skin cream regularly to reduce the itching and burning, and that he often would itch until his skin bled. These lay statements are competent regarding the Veteran's observations of his skin irritations and treatment, and to establish the presence of observable symptomatology, including frequency. See Caluza v. Brown, 7 Vet. App. 498 (1995); see also Barr v. Nicholson, 21 Vet. App. 303, 307-8 (2007). While also presumed credible, these observations are not competent to diagnose the Veteran with chloracne, acne, dermatitis, or eczema, nor link any diagnosed skin condition to service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). In November 2019 a non-VA dermatologist diagnosed the Veteran with stasis dermatitis, xerosis (dry skin), and eczema. The examiner advised the Veteran that xerosis was "easily" managed with moisturizers but that the condition may still recur. With regards to eczema, the examiner noted that herbicide exposure such as Agent Orange can cause acute skin irritation that may trigger eczema to flare at the time of exposure, and that eczema was a chronic skin condition that may flare due to other skin irritants or dryness as well. With regards to stasis dermatitis, the examiner advised the Veteran that the condition was chronic in nature that may flare when his lower legs become swollen. This opinion is not probative of a nexus to service for any of the Veteran's current skin diagnoses because the examiner did not review the Veteran's service treatment records nor provide a fact-based opinion as to the etiology of any of the Veteran's skin diagnoses. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (medical opinions based on incomplete or inaccurate factual premises are not probative). At a December 2019 VA medical examination, the Veteran reported itching and dry skin since service, and that the condition had worsened in the past 18 months. The examiner diagnosed the Veteran with stasis dermatitis and eczema, and opined that neither diagnosis was incurred in service because the Veteran's in-service skin disorder was diagnosed as acute acne only, without evidence of any other skin condition; that the Veteran's separation examination did not indicate a current skin disorder; and that his eczema and stasis dermatitis was diagnosed well after service. The examiner also noted medical research that indicated there was no known cause for eczema, but that eczema may be indicative of an over-reactive immune system that responded by producing skin inflammation, or of a genetic mutation where a person's body did not produce sufficient amounts of a protein to maintain a healthy top layer of skin. In an October 2021 addendum opinion, a VA medical examiner reviewed the Veteran's entire claims file and opined that the Veteran's current skin disorder was not incurred in service for several reasons. The examiner noted that the Veteran's only in-service skin complaint was for acne, and that it was unlikely that a dermatologist misdiagnosed the Veteran's symptomatology "given the relatively elementary diagnosis and the specialization of the clinic itself." Therefore, the examiner concluded that it was "all but certain" that the Veteran's only skin disorder during service was acne. The Board notes that the October 1971 medical examiner correctly identified that the Veteran's October 1971 treatment emanated from the "Dermatology Clinic" at the U.S. Army Hospital in Fort Polk, Louisiana. The Veteran was then specifically diagnosed with "acne vulgaris," and an assigned grade of severity. This had also followed an October 1970 consultation for an "acne problem." The October 2021 examiner explained that the Veteran's 2011 complaints about vague itching or pruritus with no demonstrable legions were inconsistent with acne and that the Veteran's acne would have been discernable. The examiner then noted the 2019 diagnoses of eczema, xerosis, and statis dermatitis. The examiner explained that none of these skin conditions would have been confused with acne and there was no evidence that these conditions demonstrated during service. Of importance to this VA examiner was that the Veteran's separation examination did not reveal any skin disorders. The examiner noted that the separation examination was generally noted to be thorough; that it included conducting a medical history of symptomatology, a physical evaluation, and a review of service medical records, to include the Veteran's report of medical history at separation; and that it was unlikely that a significant skin condition would have gone unnoted or unreported. The examiner then provided further medical details about the Veteran's current skin diagnoses. The examiner explained that statis changes were lower extremity changes due to poor circulation and were considered secondary skin changes due to a primary cause. Xerosis was a generalized pruritic skin condition with no evidence of onset during service and was not related to the Veteran's in-service acne manifestation. The examiner noted that eczema was readily discernible from acne, both in terms of manifestations and anatomic location. Relevant to the parties' joint motion for remand, the examiner noted that any skin condition caused by herbicide exposure would have been evident at the time of exposure or at least by separation. The manifestation would likely have presented as contact dermatitis and would have been differentiated from his acne. Therefore, it was less likely than not that any of the Veteran's current skin diagnoses had its nexus to service, to include herbicide exposure. The examiner summarized that the Veteran's complaints of rashes, bumps, redness, sores, and itchiness that he contended was not acne but was misdiagnosed as acne was not supported by the service medical records because eczema was easily differentiated from acne, especially by specialists; statis dermatitis was unlikely to have occurred to the Veteran at his age during service and was also readily distinguishable from acne; and there was no evidence of generalized pruritus or xerosis while in service. The preponderance of the evidence is against finding service connection for a skin disorder, to include dermatitis or eczema. There is no probative medical evidence that indicates that any of the Veteran's current skin disorder diagnoses were incurred in service, to include as due to herbicide exposure. The Veteran has continuously asserted throughout the appeal that his current skin disorder is a result of his service, to include exposure to herbicides. The Veteran is competent to report observable symptomatology of his condition and to relate a contemporaneous medical diagnosis. See Layno, 6 Vet. App. 465, 469; see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, while the Veteran has attempted to establish a nexus through his own lay assertions, the Veteran is not competent to offer opinions as to the etiology of his current skin diagnoses. See Jandreau, 492 F.3d 1372, 1377 n.4; Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Eczema and dermatitis require specialized training for determinations as to diagnosis and causation, and are therefore not susceptible to lay opinions on etiology. Thus, the Veteran is not competent to render such a nexus opinion or attempt to present lay assertions to establish a nexus between his current skin disorder diagnoses and his service. (CONTINUED ON THE NEXT PAGE) The claim for service connection is denied. The preponderance of the evidence is against the claim, and the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Anwar, Attorney-Advisor The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.