Citation Nr: 21006037 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 16-06 646 DATE: February 3, 2021 ORDER Entitlement to service connection for skin lesions, including malignant skin neoplasms is denied. FINDING OF FACT The Veteran's skin lesions, including malignant skin neoplasms did not manifest in service; are not shown to be causally or etiologically related to an in-service event, injury or disease, including exposure to the gas chamber and other chemical weapons such as blistering agents. CONCLUSION OF LAW The criteria to establish entitlement to service connection for skin lesions, including malignant skin neoplasms have not been met. 38 U.S.C. §§ 1110; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1961 to March 1964. This matter is on appeal from an August 2015 rating decision and was previously remanded by the Board of Veterans’ Appeals (Board) in September 2017, May 2019, and July 2020. Entitlement to service connection for skin lesions, including malignant skin neoplasms is denied. The Veteran contends that his skin lesions are related to his exposure to chemicals in 1962 while going through basic training at Fort Benning, including exposure in a gas chamber that he was pricked on the arm with a blistering agent, as well as with chemicals used to prepare for chemical warfare. In March 2012, the Veteran filed a claim for skin lesions (cancer) and indicated that the condition began in 1962 and continued through the present. Service connection may be granted for a disability resulting from disease or injury incurred in, or aggravated by, service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must generally show: (1) the existence of a present disability; (2) the 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. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). To deny a claim for benefits on its merits, the preponderance of the evidence must be against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990) (A veteran need only demonstrate that there is an approximate balance of positive and negative evidence' to prevail.) The Veteran's service treatment records did not contain any complaints or treatment of a skin related condition. On a February 1964 report of medical history upon separation, the Veteran denied having or ever having any reaction to serum, drug or medicine; and tumor, growth, cyst, or cancer. A clinical evaluation of the skin noted on a separation report of medical examination was normal. Post-service, VA treatment records initially noted treatment for a skin complaint in August 1990 that reported a history of the Veteran being hospitalized related to burns from a house fire in 1974. A July 1991 record noted possible basal cell carcinoma (need to rule out). A subsequent July 1991 record reported skin lesions on the scalp for three months and actinic keratosis. Another July 1991 record revealed the presence of a dermatofibroma that was removed in August 1991. In September 1991, there was a local infection of a wound status post one-month removal of dermatofibroma and a diagnosis of skin cancer on the scalp area. In January 1993, the Veteran reported that he had blister gas applied to his arm. In October 2002, the Veteran was seen for several small, brown colored moles on his face and right arm. In October 2010, he had a skin lesion on his right eyebrow that was removed in August 2010. On a January 2011 Mental Health Consult, the Veteran reported a history of having to put on a gas mask after being exposed to gas. In February 2014, he reported that he was “blistered with gas.” In April 2014, he reported that when he did not get on his mask fast enough, he was exposed to gas, and mustard gas was placed on his arm to evoke a blister. A November 2014 record noted that benign lesion and basal cell carcinoma was diagnosed on the skin right posterior auricular in October 2013 with two lesions on the back and one lesion on the left shoulder in June 2014. He also had a medical history of actinic keratosis of the scalp, face, and arms. In March 2015, he was diagnosed with basal cell carcinoma of skin and squamous cell carcinoma of forehead. A November 2018 record noted that there were no wounds, pressure ulcers, or other skin problems A July 2019 record included a problem list of squamous with such diagnoses cell carcinoma of forehead status post excision squamous cell carcinoma left frontal scalp; actinic keratosis scalp, face and arms; and basal cell carcinoma of skin right posterior auricular in October 2013 with two lesions on the back and one lesion on the left shoulder in June 2014; basal cell carcinoma nodular and superficial right postauricular area in November 2014; status post excision of left thorax basal cell carcinoma in November 2014; and status post excision of right mid-scalp basal cell carcinoma in February 2015. Also, he had a surgical history of status post excision of left frontal scalp squamous cell carcinoma in 2015 and status post excision of lesions in the right upper nasolabial fold and left preauricular area in June 2012. Private medical records from the DermatoPathology Alliance of Kentucky dated in June 2014 included a diagnosis of superficial basal cell carcinoma. An October 2014 record from Pikeville Medical Center included such diagnoses as basal cell carcinoma, superficial and nodular types. A November 2019 record noted electrodessication and curettage of a squamous cell carcinoma located on the mid-upper back squamous cell carcinoma in situ. In January 2015, a record from LabCorp revealed superficial squamous cel carcinoma and basal cell carcinoma. The Veteran was afforded a VA skin diseases examination in January 2018. The examiner diagnosed the Veteran with basal cell carcinoma from 1990; squamous cell carcinoma, diagnosed in 2015; and actinic keratoses in the 1990’s. The examiner opined that the Veteran’s condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner reasoned that the Veteran's service treatment records revealed no evidence of in-service occurrence of the lesions diagnosed and treated over the past 20 plus years. Concerning whether the post-service skin disabilities could be related to in-service exposures, the examiner acknowledged that the Veteran had related that when he was in basic training, he was pricked on the arm with a blistering agent, and was given medications and chemicals to prepare for chemical warfare. However, the examiner found that there was no evidence in the records of activity of this type, and the medical records revealed nothing that might support this position. In the July 2020 remand, the Board noted that at the very least, VA already conceded that the Veteran participated in gas chamber training in awarding service connection for PTSD, notwithstanding the fact that such participation was not documented in the Veteran’s service treatment records. As the Veteran contended that this in-service gas exposure may have, in part, caused his skin disabilities, and the Board specifically requested an opinion addressing the impact of such exposure and remanded the claim for a new opinion. In a November 2020 VA medical opinion, a VA physician reviewed the Veteran’s VA e-folder and summarized the relevant medical evidence. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The physician reasoned that the Veteran/s dermatologic or skin diagnoses included squamous cell carcinoma, basal cell carcinoma, actinic keratoses, and seborrheic keratoses. The physician stated that, “[a]ccording to the Cleveland Clinic, several skin lesions are very common and almost always benign (non-cancerous). These conditions include moles, freckles, skin tags, benign lentigines, and seborrheic keratoses. In most cases, there is no identified cause of these conditions. However, some benign skin conditions are more likely to be familial, develop after prolonged sun exposure, or come about after minor trauma to the skin. Squamous cell carcinoma is the second most common type of skin cancer in the United States, after basal cell carcinoma, with about 700,000 diagnosed each year. The risk of developing basal cell or squamous cell skin cancer is increased among fair-skinned and fair-haired people who have repeatedly been exposed to strong sunlight, individuals who had freckles as a child, and those with blue eyes. Other risk factors include taking immunosuppressants (drugs that weaken the immune system) and being exposed to industrial pollutants such as arsenic, tar, and industrial oils. Actinic keratoses are caused by exposure to UV rays from the sun or tanning beds.” The physician added that no information regarding most of these risk factors is found in the medical record; however, the separation physical does note that the Veteran has blue eyes. For the purposes of the opinion, the physician indicated that it will be taken as fact that the Veteran was exposed to the “gas chamber” (CS gas exposure having been common training for Soldiers), and that he was exposed to other chemical weapons such as blistering agents. The examiner cited research showing that “There was no convincing evidence of long-term physical sequelae from exposure to CS spray,” and that with respect to blister agents, long-term health effects are not expected after low level exposures. The physician determined that given that the Veteran’s skin conditions are all very common, and that the scientific literature offers no support for a nexus between chemical agent exposure and these skin conditions, it was his opinion that the Veteran’s several skin condition diagnoses, including malignant skin neoplasms are less likely than not (50 percent or greater probability) incurred in or caused by (the) chemical and gas exposure during service. The Board finds that November 2020 examiner's opinion constitutes competent, probative, and persuasive evidence that is based on review of the Veteran's documented medical history and assertions, research and examination. The examiner provided a rationale based on an accurate discussion of the evidence of record with support of medical literature. Prejean v. West, 13 Vet. App. 444 (2000); Guerrieri v. Brown, 4 Vet. App. 467 (1993). Thus, the Board affords the opinion significant probative weight. The Veteran has not submitted any contrary adequate medical opinion that supports this claim, or calls into question the rationale of the November 2020 examiner. The Board has considered the Veteran’s own lay assertions and, insofar as the Veteran has asserted his skin problems began during service after his exposures, the Board finds such assertions to be not credible, given his denial of having experienced any reaction to serum, drug or medicine, upon discharge from service, and his normal clinical evaluation of the skin at separation. While the Veteran may otherwise believe his history of skin disorders are due to his in-service exposures, he has not demonstrated he has the medical expertise to competently relate the diseases to his injury. (Continued on Next Page) Consequently, the Board finds the most probative evidence of record is against a finding that the Veteran’s skin disorders had onset during service, or are otherwise related to service, to specifically include his chemical exposures. Because the preponderance of the evidence is against the claim for service connection for skin lesions, including malignant skin neoplasms, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Crohe, 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.