Citation Nr: 21076962 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 17-08 079 DATE: December 28, 2021 ORDER Entitlement to service connection for a skin disorder, including tinea pedis and chloracne, to include as due to herbicide agent exposure, is denied. FINDING OF FACT The Veteran's skin disorders, including tinea pedis and chloracne, were not incurred in service or within one year of service and are not otherwise etiologically related to active service, to include as due to herbicide agent exposure. CONCLUSION OF LAW The criteria for entitlement to service connection for a skin disorder, including tinea pedis and chloracne, to include as due to herbicide agent exposure, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from August 1968 to August 1971. The Board of Veterans' Appeals (Board) remanded these matters in January 2019 and August 2021 to obtain addendum medical opinions. The requested development has been completed as the Regional Office (RO) obtained a VA medical opinion with supporting rationale sufficient to make a decision on this matter. The appeal has returned to the Board for further appellate consideration. The Board is now satisfied there was substantial compliance with the remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-147 (1999). Service Connection Under the relevant laws and regulations, 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, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Service connection is warranted for a veteran who has been exposed to a toxic herbicide agent during active military service (subject to the requirements of 38 C.F.R. § 3.307 (a)) for diseases such as AL amyloidosis, chloracne or other acneform diseases consistent with ischemic heart disease, diabetes mellitus, Hodgkin's disease, non-Hodgkin's lymphoma, porphyria cutanea tarda, multiple myeloma, prostate cancer, soft-tissue sarcomas, early-onset peripheral neuropathy, Parkinson's disease, chloracne and respiratory cancers, and B-cell leukemias. 38 C.F.R. § 3.309(e). In short, if herbicide exposure is found on either an actual or presumptive basis, then service connection of a listed qualifying disability is all but guaranteed by statute. To determine whether a Veteran was exposed to herbicide agents, VA regulations state that a veteran who served in the Republic of Vietnam during the period from January 9, 1962 to May 7, 1975, shall be presumed to have been exposed during such service to certain toxic herbicide agents, with the most common being "Agent Orange," unless there is affirmative evidence to the contrary. 38 U.S.C. § 1116; 38 C.F.R. § 3.307 (a)(6). Therefore, if a Veteran served in-country in Vietnam, they are entitled to a presumption of herbicide exposure, and need not prove actual exposure to herbicides. The Veteran served in Vietnam during this time and is presumed to have been exposed to herbicide agents. Entitlement to service connection for a skin disorder, including tinea pedis and chloracne, to include as due to herbicide agent exposure The Veteran contends that he has experienced skin rashes, swelling, boils, and sensitivity to sunlight on his hands, feet, head, neck, back, and groin since service. Although the Veteran contends his symptoms are chloracne, the record demonstrates diagnoses of tinea pedis with onychomycosis and seborrheic keratosis. He contends that his skin disorders are related to exposure to Agent Orange during service. After reviewing all the evidence currently of record, the Board determines that, while the Veteran has a current diagnosis of bullous tinea pedis with onychomycosis and seborrheic keratosis, the preponderance of the evidence weighs against finding that this disorder began during service or is otherwise etiologically related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309; Holton v. Shinseki, 557 F.3d 1363, 1366 (2009). As an initial matter, the Board finds that the Veteran is not entitled to service connection for chloracne or other acneform disease consistent with chloracne on a presumptive basis due to toxic herbicide exposure per 38 C.F.R. § 3.307(a)(6)(ii). Although the Veteran is presumed to have been exposed to herbicide agents, the evidence of record does not contain a diagnosis for chloracne or other acneform disease consistent with chloracne during or within one year of service. Specifically, the only skin-related complaints in the Veteran's service-treatment records occurred in June 1969, when he sought treatment for a groin rash, and in February 1970, when he sought treatment for foot blisters. The Veteran was not diagnosed with chloracne on either occasion, and there is no evidence of follow-up treatment for either condition during service, suggesting these were acute incidents. Of particular significance, the Veteran's June 1971 separation exam was normal with no indication of skin conditions. Moreover, the Veteran did not seek treatment for skin rashes again until August 1984, at which time he complained of recurring rashes, blisters, and itching on his hands, feet, and groin and was diagnosed with tinea pedis and tinea cruris. This occurred more than 13 years after separating from service, and he was not diagnosed with chloracne or other acneform disease at the time. Next, although the Veteran is not entitled to presumptive service connection for chloracne due to toxic herbicide exposure per 38 C.F.R. § 3.307, he is not precluded from demonstrating that his skin disorders, including tinea pedis with onychomycosis and seborrheic keratosis, were proximately due to, the result of, or aggravated by Agent Orange exposure or other in-service illness, event, or injury. See Combee v. Brown, 43 F.3d 1039, 1041-42 (Fed. Cir, 1994). However, the competent evidence fails to establish a relationship between active duty and the Veteran's current skin disorders. First, as discussed, although the Veteran received treatment for a groin rash in June 1969 and foot blisters in February 1970, the Veteran never sought follow-up treatment for either condition in service, suggesting those conditions were acute, and there is no evidence of any skin condition noted during the Veteran's June 1971 separation examination. Indeed, the records do not indicate diagnoses or treatment for skin disorders until August 1984, which is 13 years after separating from service. Therefore, continuity of symptoms since service is not shown. The Board has considered the Veteran's statements that his skin symptoms have been continuous since service. However, the Board is unable to grant service connection purely on his statements alone. As an initial matter, there is no evidence of chloracne, tinea pedis, or seborrheic keratosis in service. Moreover, the Veteran specifically denied any skin-related symptoms at his separation examination, where it is reasonable to expect that he would have mentioned it had he been experiencing such symptoms. Additionally, he did not seek treatment for rashes on his hands, feet, and groin until August 1984, 13 years after service, and did not report to physicians that his symptoms were continuous since service, but rather simply reported that he gets rashes "here and there." Therefore, continuity of symptoms is not established based on either the Veteran's statements or the evidence of record. Next, service connection may be granted if the evidence otherwise reflects that the Veteran's current skin disorders are related to service. However, after a review of all available evidence, service connection is also not warranted on this basis. Specifically, the Veteran underwent a VA examination in January 2015, and the examiner opined that the Veteran does not have chloracne but instead has several normal moles to his upper back that appear in almost everyone in the first few decades of life and are often caused by sun exposure. As such, the examiner found that the Veteran does not have chloracne that is related to active duty service. However, the examiner did diagnose the Veteran with tinea pedis and onychomycosis but did not opine as to whether these conditions are related to active duty service. As such, an addendum opinion was needed. Next, a September 2019 VA examiner opined that it is less likely than not that the Veteran's current skin disorders are related to active duty service because there was no current diagnosis of tinea pedis, chloracne, or onychomycosis found during the Veteran's examination. Furthermore, the examiner explained that if the Veteran had chloracne in the 1970s or 1980s based on lay reports, it was likely resolved with no evidence of recurrence, progression, chronicity, or residuals, because the records only demonstrate isolated incidents of treatment for tinea pedis and onychomycosis in 2006 and 2017. The examiner stated that these isolated episodes have no correlation to the Veteran's foot blisters reported during service in February 1970, and there is no evidence of any recurrence, progression, chronicity, or residuals of his in-service foot blisters. However, the medical records demonstrate that the Veteran had diagnoses of tinea pedis and onychomycosis during the period on appeal, so the VA examiner's opinion was found to be insufficient for failure to opine whether those diagnoses were related to active duty service. Next, an August 2021 VA examiner opined that the Veteran's current diagnoses of bullous tinea pedis and onychomycosis are less likely than not related to active service because there is no evidence of symptoms of or diagnoses of these conditions during service, nor were there indications of symptoms related to these conditions noted on his separation examination. Furthermore, the examiner noted that there was no diagnosis of tinea pedis until August 1984, which is 13 years after separation from service. The examiner also noted that a June 2006 Agent Orange examination noted that he did not have tinea pedis. The examiner also noted only sporadic diagnoses of these conditions in medical treatment records in 2006 and 2017, which is decades after separating from service. The examiner also addressed statements from the Veteran's fellow service members submitted in June and July 2017 that reported they observed spots on the Veteran's head and neck during service. However, the examiner noted that these statements do not mention the Veteran's feet, further supporting that his tinea pedis and onychomycosis are less likely than not related to service. Additionally, the examiner opined that it is less likely than not that Veteran's current skin disorders are related to herbicide agent exposure during service because there is no current conclusive evidence that exposure to herbicide agents can cause tinea pedis or onychomycosis. Because the examiner reviewed the record, considered the lay statements of the Veteran and his fellow service members, and supported the opinion with thorough rationale consistent with the medical evidence of record and medical literature, the Board finds it highly probative. Aside from the VA examinations, there is no other evidence of record to support that the Veteran's skin conditions are related to active duty service. Additionally, although the VA examiners did not address the Veteran's seborrheic keratosis, which was diagnosed in October 2017 and January 2019, the medical treatment records specifically state that this condition is not consistent with chloracne and is both benign and usually hereditary. Furthermore, there is no evidence of seborrheic keratosis during or within one year of active duty service to support remanding for an additional opinion, as there is no evidence to support the condition may be related to active service. McClendon v. Nicholson, 20 Vet. App. 79 (2006). Similarly, although the Veteran reported recurrent painful rashes and boils on his groin during his first two VA examinations, he was examined by the January 2015 VA examiner and sought medical treatment consistently through as recently as September 2021 and there is no evidence of any diagnosis of a condition related to groin rash during the period on appeal. Specifically, the last time the Veteran was diagnosed with a groin rash condition was in August 1984 when he was diagnosed with tinea cruris, which was 13 years after separating from service. As such, the evidence does not support that the Veteran has a current groin rash disorder. While the Veteran's representative argues that an additional VA examination is necessary because the Veteran has not been scheduled for an examination during the periods where he is experiencing the alleged skin symptoms, the medical records do not reveal that the Veteran sought treatment for such symptoms before or after VA examinations other than during the periods already discussed, and the symptoms noted in the medical records are consistent with the diagnoses noted during the Veteran's VA examinations. As such, the evidence does not support the Veteran's contentions that he experiences flare-ups that were not occurring during the VA examinations to warrant a remand for an additional opinion. Additionally, the Veteran reported to the January 2015 VA examiner that he receives treatment for such severe skin symptoms from the private sector. Despite the RO giving the Veteran multiple opportunities to submit his private treatment records, the Veteran has failed to submit additional evidence supporting his claims. As such, the Board finds that a remand is not warranted as the evidence of record is sufficient to find that the Veteran's current skin conditions are not related to active service. In arriving at these conclusions, the Board has considered, in addition to the entire evidence of record, the statements of the Veteran and his fellow service members relating his current skin disorders to his active service. While lay statements may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1373, 1377 (Fed. Cir. 2007). In the present case, the Veteran and his fellow service members are lay persons without appropriate medical training and expertise, and thus, are not competent to make etiological conclusions regarding the cause of his skin disorders, especially given that the evidence fails to demonstrate such symptoms in service, or any other in-service incident, illness, or injury to which such a condition may be presently linked. The Board concludes that the weight of the evidence is against the claims for service connection and there is no other doubt to be otherwise resolved. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The appeal is denied. 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. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Veltri, Associate Counsel