Citation Nr: A21020684 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 211122-199643 DATE: December 30, 2021 ORDER Effective July 13, 2020, a 60 percent rating, but no higher, for dermatitis of the plantar skin medially, both feet, with onychomycosis of the toenails ("skin condition") is granted. FINDING OF FACT Since July 13, 2020, the Veteran's skin condition has required near-constant systemic therapy. CONCLUSION OF LAW Effective July 13, 2020, the criteria for a rating of 60 percent, but no higher, for the Veteran's skin condition have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 3.400(o)(2), 4.1, 4.3, 4.7, 4.118, Diagnostic Code (DC) 7806. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from March 1961 to March 1964 and the United States Air Force from July 1976 to June 1999. This matter comes before the Board of Veterans Appeals (Board) on appeal from a November 2021 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2021, the RO issued a decision denying the Veteran's claim for an increased rating for his service-connected skin disability. In October 2021, the Veteran filed a VA Form 20-0996, Decision Review Request, seeking Higher-Level Review of the August 2021 decision. Pursuant to the Veteran's request for a Higher-Level Review, the RO issued a rating decision on November 19, 2021, wherein VA continued the decision from the August 2021 rating decision. Later that month, the Veteran disagreed with the November 2021 rating decision and filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) and selected Direct Review by a Veterans Law Judge. See 38 C.F.R. § 20.202. Accordingly, based on the Veteran's selections of Higher-Level Review and Direct Review by a Veterans Law Judge, the Board is limited to review of the evidence in the record up and until the August 2021 rating decision. See 38 C.F.R. § 20.301. Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; and where there is a question as to which of two evaluations apply, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Factual Background and Analysis The Veteran was awarded service connection for his skin condition in a September 1999 rating decision and was assigned a noncompensable disability evaluation, effective July 1, 1999. The Veteran submitted a claim for an increased disability rating for his skin condition in April 2021. The Veteran's skin condition is rated under the General Rating Formula For The Skin ("General Rating Formula"). 38 C.F.R. § 4.118, DC 7806. Under the General Rating Formula, a non-compensable rating is warranted for conditions involving less than 5 percent of the entire body or less than 5 percent of the exposed areas affected, and no more than topical therapy required over the past-12-month period. A 10 percent rating is warranted for involvement of 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; for intermittent 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 for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is warranted for characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or for 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 maximum 60 percent rating is warranted for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; for constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. Id. Note (a) to 38 C.F.R. § 4.118 explains that systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. The Board has reviewed the evidence of record, with an emphasis on the evidence relevant to the Veteran's claim. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's claim. After a review of all the lay and medical evidence of record and after considering the benefit-of-the-doubt rule, the Board finds that the Veteran's service-connected skin condition most closely approximates the criteria for a 60 percent rating, effective July 13, 2020. 38 C.F.R. §§ 3.400(o)(2); 4.118, DC 7806; Gaston v. Shinseki, 605 F.3d 979, 983 (2010). The Veteran received a VA skin diseases examination in July 2021. The examiner noted the Veteran's symptoms had progressed since the onset of the Veteran's condition. The examiner noted the Veteran had taken the following medications to treat his skin condition: Voriconazole (oral), Lamisil/Terbinafine (oral), and Griseofulvin (oral). The examiner characterized the Veteran's use of Voriconazole as "6 weeks or more, but not constant" in the past 12 months. In May 2021, VA obtained treatment records from the Veteran's private dermatologist. The Veteran's private treatment records include a July 13, 2020 treatment note in which the Veteran's dermatologist discussed prior topical treatment and stated that the treatment plan going forward would be for oral medicationspecifically, Griseofulvin and Lamisil, twice a day continuously. The associated counseling note indicated that oral therapy was more effective than topical therapy but noted that serious side effects could ensue with systemic treatment. Subsequently, the Veteran was prescribed oral Voriconazole to treat his skin condition. Specifically, a May 2021 treatment note indicated that the Veteran had been prescribed Voriconazole twice daily and continuously. The plan moving forward indicated he was to take Voriconazole for the first seven (7) days of each month. It is unclear from the record whether the Veteran was continuing his other oral medications at that time. Based on the foregoing, and resolving reasonable doubt in the Veteran's favor, the Board finds the criteria for a 60 percent rating under DC 7806 were met effective July 13, 2020. See 38 C.F.R. § 4.118, DC 7806. July 13, 2020 is the appropriate effective date, as that was the date within the one-year period prior to the Veteran's claim on which an increase in the severity of the Veteran's skin disability was factually ascertainable. 38 C.F.R. § 3.400(o)(2); Gaston, 605 F.3d at 983. While the July 2021 VA examiner described the Veteran's use of Voriconazole as 6 weeks or more, but not constant in the past 12 months, as noted above, he failed to address the Veteran's daily use of Lamisil and Griseofulvin in the months prior to the Veteran's use of Voriconazole, and it is unclear whether the Veteran was continuing that medication in addition to using Voriconazole. Moreover, although the Voriconazole was to be taken one week per month, there is no indication in the record that this continuous course of monthly treatment was to be stopped at any point. In any event, resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's use of the above-described oral medications to treat his skin condition during the claim period demonstrates near-constant systemic therapy. In sum, a 60 percent rating is granted for the Veteran's skin disability throughout the claim period, effective July 13, 2020. 60 percent is the highest rating available under the General Rating Formula, and there is no indication that rating the Veteran's skin condition under another diagnostic code would be more appropriate. 38 U.S.C. § 5107; 38 C.F.R. § 4.3, 4.7, 4.118. L. STEPANICK Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Nestander, Jessica S. 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.