Citation Nr: 21006377 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 14-14 352 DATE: February 4, 2021 ORDER A 10 percent rating for ringworm is granted. REMANDED Entitlement to a rating higher than 10 percent for the service-connected ringworm is remanded. FINDING OF FACT Resolving all reasonable doubt in the Appellant’s favor, the service-connected ringworm affected more than 5 percent, but not 20 percent or more, of the Veteran’s entire body. CONCLUSION OF LAW The criteria for a 10 percent rating for the service-connected ringworm disability have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Code 7813. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1947 to June 1950. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from a December 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). During the pendency of the appeal, the Veteran unfortunately, died in July 2011. His surviving spouse has been properly substituted as the Appellant in this claim. See 38 C.F.R. § 5121A; Breedlove v. Shinseki, 24 Vet. App. 7 (2010). By way of procedural background, the Board issued a June 2018 decision denying a compensable rating for the service-connected ringworm. The Appellant timely appealed the denial to the Court of Appeals for Veterans Claims (Court), and in July 2019, the Court granted a joint motion for remand, which vacated the June 2018 Board decision and remanded the claim for further consideration. Subsequently, the Board remanded the claim in December 2019 and October 2020 for VA medical opinions. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). 1. A 10 percent rating for tinea corporis (ringworm) is granted. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran’s service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value 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). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). 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). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Here, the Veteran seeks a compensable rating under Diagnostic Code 7813 (dermatophytosis) for ringworm. The Veteran filed an increased rating claim in November 2010. When the Veteran filed his claim, Diagnostic Code 7813 (applicable to dermaphytosis) directed that the disability should be evaluated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending on the predominant disability. Based on the Veteran’s diagnosis of ringworm and the medical and lay statements describing the Veteran’s symptoms, the Board finds that Diagnostic Code 7806 is the most appropriate to rate the ringworm disability. Although there is medical evidence indicating that the ringworm occasionally affected his face, there is no evidence that it resulted in scars or disfigurement that would warrant a rating higher than 10 percent under the applicable diagnostic codes. See January 2011 VA treatment record. Furthermore, neither the Veteran nor the Appellant have asserted that the ringworm predominately manifested as disfigurement of the head, face, or neck or scars. Therefore, Diagnostic Codes 7800 to 7805 are not for application. Under Diagnostic Code 7806, a noncompensable disability rating is warranted when less than 5 percent of the entire body or less than 5 percent of the exposed areas is affected, and; no more than topical therapy was required during the past 12-month period. A 10 percent disability rating is warranted when 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 are affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive medications are required for a total duration of less than six weeks during the past 12-month period. A 30 percent disability rating is warranted when 20 to 40 percent of the entire body is affected; 20 to 40 percent of exposed areas are affected; or intermittent systemic therapy such as corticosteroids or other immunosuppressive medications are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent disability rating is warranted when more than 40 percent of the entire body or more than 40 percent of exposed areas are affected; or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive medications are required during the past 12-month period. 38 C.F.R. § 4.118. During the pendency of the Veteran’s appeal, 38 C.F.R. § 4.118 was amended, effective August 13, 2018. 83 Fed. Reg. 32,592 (July 13, 2018), revised, 83 Fed. Reg. 38,663 (Aug. 7, 2018). These amendments revised Diagnostic Code 7806 to evaluate these disabilities under the General Rating Formula for the Skin. However, the new amended regulations apply on or after August 13, 2018, the date the regulations became effective. Here, the Veteran died in July 2011. Thus, only the regulations effective prior to August 13, 2018 will apply. In Johnson v. Shulkin, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the “use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case” under the pre-amended criteria for 38 C.F.R. § 4.118, Diagnostic Code 7806. 862 F.3d 1351, 1356 (Fed. Cir. 2017). The Federal Circuit noted that a topical treatment administered on a large enough scale to affect the body as a whole could constitute systemic therapy. Id. at 1355. In Warren v. McDonald, the United States Court of Appeals for Veterans Claims (Court) held that “systemic therapy,” as applicable to pre-amended Diagnostic Code 7806, was not limited to corticosteroids or immunosuppressive medications, and that the Board must consider whether a given treatment is “like” a corticosteroid or other immunosuppressive medication to determine whether such treatment was a systemic therapy. 28 Vet. App. 194 (2016). In Burton v. Wilkie, 30 Vet. App. 286 (2018), the Court interpreted Johnson to mean that for a treatment to be systemic, it must affect the entire body in its treatment of the condition. Accordingly, consideration must be given on how a topical treatment works and how it affects the body as a whole, not only the amount of skin area to which the medication is applied. The Court held that such determination was a factual question, and that the side effects of a topical therapy were irrelevant to this consideration. In addition, the Court held that the questions of whether a topical treatment was systemic and whether a systemic therapy was “like” a corticosteroid or other immunosuppressive medication did not need to be addressed in a particular order since both elements must be present to justify a higher rating under Diagnostic Code 7806. As an initial matter, the Veteran was awarded service connection for “ringworm” in an April 2008 Board decision, which was implemented by a May 2008 rating decision, and assigned a noncompensable rating effective May 2, 2002. Turning to the pertinent evidence of record, November 2009 VA podiatry records indicated the Veteran had mycotic toenails at the first toe on the right foot and toes one through three on the left foot. They were crumbly and approximately 8 millimeters thick with thick mycotic debris. The assessment included calluses, clavus, non-insulin dependent diabetes mellitus (NIDDM), peripheral neuropathy, PVD, four mycotic nails, onychogryphosis, and “resolution of tinea pedis.” The toenails were trimmed. A January 2010 VA podiatry note reported identical findings to the November 2009 VA podiatry note. In addition, the Veteran was prescribed Lamisil cream as needed. See also March 2010 VA treatment record. A February 2010 VA treatment record showed the Veteran reported having a chronic rash outbreak on his inner thighs since 1948 in Japan. On physical examination, no rash was found. A March 2010 VA primary care treatment record indicates the Veteran had chronic dermatitis on the current problem list. It also showed the Veteran was prescribed clotrimazole topical cream to be applied daily for fungal infection, triamcinolone acetonide for rash and itch, and terbinafine HCL cream to be applied topically twice daily. A May 2010 VA podiatry treatment record noted similar findings to previous podiatry records; however, no mycotic toenails were reported, but Lamisil was prescribed as needed. See also June 2010 VA treatment records. A July 2010 VA pharmacy note indicated the Veteran was prescribed Terbinafine cream that was to be applied topically twice a day to affected web spaces on the right and left feet for tinea pedis. See also November 2009, December 2009, January 2010, March 2010, April 2010, May 2010 and June 2010 VA treatment records. A July 2010 VA podiatry note indicated that only the 1st toes bilaterally were long and thick. Lamisil cream was prescribed as needed. An August 2010 problem list included chronic dermatitis. The assessment for this visit also included chronic stable dermatitis. An August 2010 VA podiatry note indicated the Veteran’s toenails were not long or thick at this appointment. Lamisil cream was again prescribed as needed. A September 2010 VA audiology record show the Veteran reported he had jungle rot inside his ears, and he could not wear his hearing aids because of it. An October 2010 VA podiatry record noted the Veteran had long toenails and some were mycotic. All the toenails were trimmed, and Lamisil cream was prescribed as needed. in November 2010, the Veteran submitted a November 2007 VA treatment addendum record that indicated that he was diagnosed with tinea corporis (ringworm) during the October 2007 VA examination for service connection, and that it was at least as likely as not related to service. The Veteran also submitted a November 2010 statement that indicated he developed ringworm in service and had chronic ringworm ever since service. He reported his claim was previously denied because VA could not find evidence of ringworm treatment in his service treatment records. He enclosed the November 2007 VA medical opinion that contained a positive nexus to service for the chronic ringworm disability. December 2010 VA podiatry note indicated the Veteran had bilateral lesions on his feet. He denied breaks in the skin at that time. The Veteran had non-service connection diabetes mellitus. The skin on the feet appeared atrophic bilaterally. There was a thick callus sub 5 met heads bilaterally and plantar medial hallux toes. The lesions on the fifth left toe was very deep with bleeding and reduction. He had very thick callus on the right and left plantar heels. His toenails were long, and some were mycotic. The assessment was onychogryphosis, calluses, clavus, NIDDM, PVD, and peripheral neuropathy. The nails were trimmed. The December 2010 VA medication list included triamcinolone acetonide, which was to be applied twice a day for rash and itch. See also March 2010, May 2010, June 2010, August 2010, September 2010, October 2010, and November 2010 VA medication lists. The December 2010 medication list also included a prescription for fluocinonide, which was to be topically applied twice a day for rash and itch. A January 2011 VA pharmacy note indicated the Veteran had ringworm on his legs and face, and it had been there for 60 years. According to the VA clinical pharmacist, the Veteran had a 90-day prescription for Terbinafine 250mg daily that he had not yet filled. He planned to fill it at his next primary care appointment. The pharmacist told the Veteran that Terbinafine could affect his international normalized ratio (INR), a condition related to his blood thinner medication, and that his INR would need to be monitored while he took the Terbinafine. A January 2011 VA addendum treatment note indicated the Veteran had obtained a prescription for Lamisil, to be applied daily, from a private treatment provider. A February 2011 addendum treatment record reported the Veteran called to let his physician know he had stopped using the Lamisil because he felt weak and tired. A March 2011 VA podiatry record showed the Veteran’s toenails were not long at this appointment. The assessment did not include any form of tinea or ringworm. The Veteran was prescribed Lamisil as needed. Another March 2011 VA medication list included Clotrimazole topically for fungal infections twice daily. In June 2011, the Veteran was prescribed topical triamcinolone acetonide daily for itch and rash and Terbinafine HCL tablet (oral) once daily for fungal infection. The Appellant identified private treatment records that pertained to the ringworm disability. However, when the Appellant requested these records, they had been destroyed and were unavailable. See March 2018 statement. The Appellant submitted a November 2012 notice of disagreement. The Appellant reported that the Veteran had flare ups of the ringworm disability that would cover more than 5 percent of his body. The Appellant indicated the ringworm disability spread to her. She was responsible for spreading the cream on her husband to treat the ringworm, so she had personal knowledge and could verify that the ringworm covered more than 5 percent of his body. She did not indicate how much of his body the rash covered or describe what areas were affected. She also indicated he took oral medication for the ringworm on occasion. See also April 2014 VA Form 9. The Veteran’s son, E.W., submitted a statement in April 2018. E.W. took the Veteran to a VA hospital for medical treatment for the ringworm a couple of years before the Veteran’s death. The Veteran was seen by a nurse practitioner at VA who found paperwork that the Veteran was treated for ringworm twice during active service in Japan. E.W. indicated that he knew of the two treatment records in service for ringworm because he saw them with his own eyes. In September 2019, the Appellant submitted a brief. The Appellant stated that a compensable rating should be awarded for the ringworm disability because there was evidence that more than five percent of the Veteran’s body was covered in a rash during flareups, he took systemic oral medication to treat the ringworm, he was prescribed corticosteroids for the ringworm, and the prescribed medications were used for six weeks or more during a 12 month period. Furthermore, the Appellant asserted that if the Veteran was prescribed oral medications for ringworm treatment, then he had been prescribed the oral medication for at least six weeks during the previous year as the treatment records regularly listed prescriptions for both oral and topical antifungals and corticosteroids for skin conditions. In addition, the Appellant contends that the lay statements of record were credible because these symptoms were observable by their senses, the treatment records show the Veteran was prescribed oral medication (Terbinafine) in June 2011, and the contemporaneous medical records supported the lay statements of record. Furthermore, the Appellant also argued that the Board should find Clotrimazole constituted systemic therapy that is like or similar to a corticosteroid or other immunosuppressive therapy. In addition, the Appellant contends that Triamcinolone Acetonide and Fluocinonide, steroids, were prescribed for the Veteran’s ringworm and that they also qualify as systemic therapy. A VA medical opinion was obtained in May 2020. The clinician, a physician, indicated a 2007 VA examination, which included a physical examination of the Veteran, reported the service-connected ringworm affected less than 5 percent of the entire body and less than 5 percent of exposed areas, and his condition did not require intermittent systemic therapy such as corticosteroids or other immunosuppressive medications for a total duration of 6 weeks of more during any relevant 12 month period. No suspicious lesions were noted. There were poorly defined areas of slightly dry scaly skin, but there was no change in the surface contour of the areas affected, tenderness, or open lesions. The lesions on the Veteran’s skin covered less than one percent of the total skin area and 0 percent was exposed. VA treatment records between February 2000 to June 2011 did not identify any significant signs or symptoms associated with ringworm or tinea corporis. There was no evidence of more than topical therapy, and no evidence that more than 5 percent of the body was affected. Based on the review of the record, the clinician concluded less than 5 percent of the Veteran’s body was affected by the ringworm or tinea corporis. The May 2020 clinician also found that there was no evidence of the need for corticosteroids or immunosuppressive therapy to treat the ringworm. The clinician indicated the Veteran was prescribed Lamisil, clotrimazole, triamcinolone acetonide, terbinafine, and fluocinonide creams to treat the Veteran’s ringworm. The clinician also explained that Lamisil, clotrimazole, and terbinafine were all antifungal agents used to treat fungal infections, to include ringworm. The claims file and pertinent treatment records listed triamcinolone acetonide repeatedly in the medication list for a rash/itch. However, the clinician did not find any indication as to what skin condition this medication was treating. The clinician concluded, since the treatment records did not document any other skin condition other than tinea corporis, it was at least as likely as not that the triamcinolone acetonide was prescribed for irritation caused by the tinea corporis rather than another skin condition. The clinician also indicated that Fluocinonide was only mentioned by the Appellant and the joint motion for remand before the Court, and it was not listed in the medical evidence of record. Despite that finding, the examiner found that Fluocinonide was likely prescribed to treat a skin rash caused by the tinea corporis. Nevertheless, neither triamcinolone acetonide nor Fluocinonide, although topical steroid creams, constituted systemic therapy. The clinician explained that Fluocinonide, a high potency steroid cream, and triamcinolone acetonide, a mid-potency steroid cream, both worked in the same way. They are applied to the skin to reduce local inflammation and irritation. Side effects included thinning of the skin and stretch marks. As previously discussed by the clinician, they were at least as likely prescribed to treat inflammation and irritation associated with the tinea corporis, in absence of an alternative skin diagnosis. If these medications were used over a large portion of the skin for a prolonged period of time, there could be systemic absorptions with iatrogenic Cushing’s syndrome. However, there was no evidence that the Veteran used the Fluocinonide for a prolonged period of time, and since less than 5 percent of the Veteran’s body had ringworm, the use of these medications over a large area was unlikely. The clinician also indicated there was no evidence the Veteran used these medications on a regular basis, and intermittent use involving a small area was exceedingly less likely than not to constitute systemic therapy. In addition, the other medications prescribed were not in any way a corticosteroid or other immunosuppressive medication. There was no evidence in the medical literature that these other medications were absorbed to any significant degree when applied intermittently to a small surface area of the body and these additional medications possessed no immunosuppressive properties. The May 2020 VA medical opinion also noted the Veteran was prescribed oral Terbinafine HCL to treat the tinea corporis, and this medication was systemic therapy. Oral terbinafine HCL is an antifungal medication used to treat fungal infections, including ringworm. It is taken by mouth and is absorbed systemically. The clinician explained that these medications were delivered by the blood stream to cutaneous areas involved with the fungal infection. A May 2020 VA addendum medical opinion was obtained after it was clear that the clinician was not previously provided a copy of the September 2007 VA examination. The clinician again reviewed the record and determined that the early May 2020 medical opinion was unchanged and concluded the total exposed area affected by the tinea corporis, based on the September 2007 physical examination of the Veteran, was less than 5 percent of the body. The clinician also noted that, because the Veteran was unavailable for a physical examination, the only way to assess the extent of the involvement of the tinea corporis was by a record review. Another retrospective VA medical opinion was obtained in October 2020. The clinician, a physician, noted that all available records in the claims file had been reviewed and considered in rendering these medical opinions. The clinician noted that the only VA examination of record with a physical examination of the Veteran was conducted in September 2007, which was four years prior to the Veteran’s increased rating claim. At that time, the Veteran presented with frequent recurrences of ringworm with small boil like lesions that itched and resolved with antifungal cream (clotrimazole 1 percent). His rash was intermittent. It was unclear how often he used this cream to treat his rash. However, he denied systemic treatment for the infection. He was also initially prescribed Ketoconazole 2 percent cream for approximately one month to be applied topically one to five times per day. During the previous 12 months, he used the cream three to five times per day. June 2009 and August 2009 VA treatment records show he was diagnosed and treated for non-service-connected dermatitis, and a March 2010 VA treatment record included chronic dermatitis on the Veteran’s active problem list. After a review of the record, the October 2020 clinician concluded that it was at least as likely as not that the total area affected by the ringworm was less than 5 percent. The clinician reported that the May 2008 rating decision concluded that the tinea corporis covered less than 1 percent of the total skin and 0 percent was exposed. The Veteran was again evaluated in June 2009 for a rash, at which time the VA treatment record noted no rash was present. The 2012 rating decision noted that additional evidence had been received, to include VA treatment records, evaluations, and examination reports dated between February 2000 and June 2011, but none of this evidence included any significant symptoms or signs associated with the ringworm disability. There was also no evidence of anything more than topical therapy, no evidence that 5 percent or more of the body was affected, and no evidence for the need of corticosteroid or immunosuppressive therapy. The July 2007 VA examination stated that, on physical examination, there were no suspicious lesions, clubbing, or deformities to digits. Capillary refill to fingers and toes was good. There were poorly defined areas of slightly dry, scaly skin with no color change or elevation to depression. The right axillary area with macerated bright red area to axillary fold, measured 4.5 centimeters long along the fold and 3.47 centimeters high in oval centered over fold. Skin scrapings were taken from this lesion. No change in surface contour of the area, no tenderness, and no open lesions were noted. It covered less than 1 percent of the total skin and 0 percent of the exposed skin. The Appellant previously explained that she spread the topical medication, in the form of a cream, on the Veteran and that the ringworm covered more than 5 to 7 percent of his body, which was interpreted to represent widespread application of topical medication. The Veteran and the Appellant also noted that at the time of the initial diagnosis in 1948, he had extensive cutaneous involvement with rash involving a large portion of his trunk, which was the worst the ringworm had ever been. The Appellant had also asserted that the Veteran had episodic recurrences of the ringworm with severe pruritus, which required topical medications applied 5 times per day for control. The extent of the associated rash was not quantitated. Based on extensive review of the record, the clinician concluded that the ringworm had never been observed to involve more than 5 percent of the body surface, either exposed or unexposed, and more likely than not only affected less than 1 percent of the unexposed surface area. In addition, the axillary rash was at least as likely as not cutaneous candidiasis and not ringworm. The clinician noted there was a fungal chart from October 2007 showing a 1+ candida result. While the site of this candida result was not specified, it was at least as likely as not taken from the axillary scraping discussed above. The October 2020 clinician further concluded that the only medications prescribed to treat the ringworm were the topical Clotrimazole and topical Lamisil (Terbinafine). Treatment with triamcinolone and fluocinonide were at least as likely as not used to treat the chronic nonspecific dermatitis, which was repeatedly referred to in the VA treatment records between 2007 and 2011. There was also a VA treatment note referring to treatment of left facial dermatitis with Lidex (fluocinonide). Topical steroids such as triamcinolone and fluocinonide are sometimes used for severe pruritis associated with ringworm infection, but more likely than not were used to treat the nonspecific dermatitis. The clinician noted that the VA records are unclear as to which topical therapies were used to treat what skin conditions. The October 2020 VA medical opinion also explained that the topical medications prescribed for the ringworm were not like a corticosteroid or other immunosuppressive medication. Topical antifungal agents were designed to damage and kill the fungal infection that caused ringworm. This topical medication is in the azole family, inhibit the enzyme lanosterol 14-alpha-demethylase, a cytochrome P-450 dependent enzyme, that converts lanosterol to ergosterol. Inhibition of this enzyme results in unstable fungal cell membranes and causes them to leak. Topical antifungals, to include Lamisil, clotrimazole, and terbinafine cream do not possess immunosuppressive properties and are not corticosteroids. Further, the October 2020 medical opinion noted the Veteran was prescribed oral Terbinafine in 2004 and 2011 for short term use, but the records are not clear for what condition it was prescribed. The examiner indicated the oral Terbinafine can be used to treat both tinea pedis that is not responding to topical therapy, and less commonly, tinea corporis. Records also indicated the Veteran was diagnosed and treated for tinea pedis, which is distinct from ringworm or tinea corporis. It is at least as likely as not that the oral Terbinafine was used to treat tinea pedis and not tinea corporis. Oral Terbinafine is considered systemic therapy as it is taken orally, absorbed through the GI tract, and distributed throughout the body by the blood stream once absorbed. Topical antifungal creams were listed on almost every VA treatment note from 2007 to 2011 and were prescribed to be used twice daily on affected areas. The clinician concluded that it was at least as likely as not that the topical antifungals were to treat the tinea corporis. There was no indication or documentation as to the frequency with which the medications were refilled. The use of the oral Terbinafine was short term, at least as likely as not for a period of two weeks in 2004 and again in 2011. The clinician noted that, while the VA treatment records were not clear that treatment period was only two weeks of oral Terbinafine, it is not generally listed on the Veteran’s records as a chronic medication, unlike the topical antifungal creams. As discussed in a prior Board remand, the May 2020 VA medical opinion was inconsistent with the VA treatment records and was, in part, based on a faulty factual premise when it found there were no other skin disabilities discussed in VA treatment records other than ringworm. Furthermore, the examiner erroneously relied on findings in the June 2018 Board decision that had been set aside by the Court. See October 2020 BVA remand. Thus, the May 2020 VA medical opinion has been assigned no probative weight. After a review of the evidence, both lay and medical, the Board resolves all reasonable doubt in favor of the Appellant and finds the evidence is at least in equipoise that the ringworm affected more than 5 percent of the Veteran’s total body, which warrants a 10 percent rating. The Appellant’s statements and descriptions of how much of the Veteran’s body the ringworm affected are competent as the Appellant had personal knowledge of this fact because she was the one to apply the topical creams to the Veteran’s affected areas. The Board acknowledges the October 2020 VA medical opinion that determined the ringworm affected less than 5 percent of the Veteran’s body; however, the Board finds it to be less probative as it was based on the historical September 2007 VA examination findings, which was more than 3 years before the current appellate period. In addition, the October 2020 VA examiner also conceded the VA treatment records, for which the opinion was primarily based, are unclear in many ways. Thus, the most probative evidence of record of the current severity of the Veteran’s symptoms during the appellate period are the lay descriptions from the Veteran and Appellant. The Board has no reason to doubt the credibility of the Veteran or the Appellant in this case, especially given the lack of contemporaneous physical examinations and other contemporaneous medical evidence to the contrary. In addition, the Veteran’s statements as to how the ringworm affected his body were consistent before his death, and the Appellant’s description of the symptoms she observed have also been consistent throughout the appellate period. Thus, resolving all reasonable doubt in the Veteran’s favor, a 10 percent rating for the service-connected ringworm is warranted. However, the Board also finds that there is no lay or medical evidence to support that the ringworm affected 20 percent or more of the Veteran’s entire body or 20 percent or more of exposed areas to warrant a rating higher than 10 percent based on these criteria. Thus, the only question that remains is whether the treatments prescribed for the Veteran’s ringworm constitute systemic therapy, to include whether they act upon the body like a corticosteroid or immunosuppressive therapy and for what duration these medications were required. Entitlement to a rating higher than 10 percent is warranted is addressed in the remand section below. REASONS FOR REMAND 2. Entitlement to a rating higher than 10 percent for the service-connected ringworm is remanded. The Board finds another VA medical opinion is necessary before the claim can be decided. A remand confers upon a claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). In the December 2019 and October 2020 remand directives, the clinicians were asked to explain whether the topical medications prescribed for the ringworm were “like” a corticosteroid or other immunosuppressive medication. In both the May 2020 and October 2020 VA medical opinions, the clinicians merely stated that the topical medications for ringworm were “not corticosteroid or immunosuppressive drugs.” The October 2020 examiner went a step further to explain how topical antifungals work; however, the examiner did not explain how corticosteroids or other immunosuppressive therapy works and contrast the two to explain why a topical antifungal is not systemic therapy “like” a corticosteroid or other immunosuppressive medication. The examiner also did not offer a conclusion or explanation as to whether the topical antifungals were systemic. On remand, an opinion must be provided with a discussion of whether the (1) non-steroidal anti-fungal topical creams prescribed for the ringworm are considered systemic, and if so, (2) whether they function “like” a corticosteroid or other immunosuppressive therapy. See Johnson, 862 F.3d at 1356; Warren, 28 Vet. App. at 194; Burton, 30 Vet. App. at 286. In addition, the October 2020 VA examiner reported the Appellant and the Veteran described that he had flare ups of the ringworm, which the examiner characterized as episodic pruritis. In addition, the Appellant indicated the pruritis associated with the ringworm required topical medications up to five times per day during a flare up. Subsequently, the October 2020 examiner concluded that the topical corticosteroids, such as triamcinolone and fluocinonide, were “sometimes used for severe pruritis associated with tinea corporis infection, but were more likely than not used to treat nonspecific chronic dermatitis… The VA records do not otherwise state which topical therapies were used to treat which skin conditions.” The October 2020 VA examiner failed to explain why he concluded the topical corticosteroids were more likely used to treat the non-service-connected dermatitis and less likely to treat the ringworm. The Board acknowledges that it could ask the examiner to further explain this medical opinion; however, with the limited VA treatment records, no private treatment records, no physical examination during the appellate period, the ambiguity in the records as to which medications were prescribed for which skin disability, and the examiner’s concession that topical corticosteroids could have been prescribed for pruritus associated with the service-connected ringworm, which is a symptom the Veteran contends he experienced, the Board construes any reasonable doubt in favor of the Veteran and finds the topical corticosteroids were used to treat a pruritic rash associated with the service-connected ringworm. In light of the Board’s conclusion herein that the topical corticosteroids will be construed as having been used to treat pruritis associated with the service-connected ringworm and the Board’s conclusion that more than 5 percent of the Veteran’s body was affected by the ringworm, on remand, a VA medical opinion should be obtained as to whether the topical corticosteroids prescribed in this case are systemic therapy and the likely duration of use of the corticosteroids. The matters are REMANDED for the following action: 1. Obtain another VA medical opinion from an appropriate clinician. A complete copy of this decision must be provided to the examiner, who must review it in its entirety. After a thorough review of the claims file, the examiner must address the following: a) Provide an opinion as to whether the topical corticosteroids prescribed to the Veteran in this case constitute systemic therapy. The information listed below by the asterisks should be considered by the examiner in rendering the requested medical opinion. *Considering the limited VA treatment records, no VA physical examination during the appellate period, the ambiguity in the treatment records as to which medications were prescribed for which skin disability, and the examiner’s October 2020 concession that topical corticosteroids could have been prescribed for a pruritus associated with the service-connected ringworm, a symptom the Veteran and Appellant contends he experienced, the Board construes all reasonable doubt in the Veteran’s favor and finds the topical corticosteroids were at least as likely as not used to treat a pruritic rash associated with the service-connected ringworm. *The Board has also determined that the evidence is at least in equipoise that the service-connected ringworm affected more than 5 percent, but not 20 percent or more, of the Veteran’s body. b) If the topical corticosteroids prescribed to the Veteran are determined to be systemic therapy, provide an opinion as to the duration of the systemic therapy (e.g. less than 6 weeks during a 12-month period, 6 weeks or more, but not constantly, during a 12-month period, or constant or near-constant use during a 12 month period). b) For each topical non-steroidal medication prescribed for the treatment of the ringworm disability, provide an opinion as to whether each medication is (i) a systemic medication and (ii) whether it functions “LIKE” a corticosteroid or other immunosuppressive medication. *The Board understands that the topical non-steroidal medications are not, in fact, corticosteroids or immunosuppressive medications. The question in this case is whether the topical non-steroidal medications are systemic medications and whether they function on the body “like a corticosteroid or immunosuppressive medication.” See Johnson, 862 F.3d at 1356; Warren, 28 Vet. App. at 194; Burton, 30 Vet. App. at 286. c) Provide an opinion as to whether the Oral Terbinafine, which has already been determined to be systemic in nature, functions “LIKE” a corticosteroid or other immunosuppressive medication. d) For each antifungal treatment that has found to be (i) systemic (to include the oral Terbinafine and any topical antifungals that have been determined to be systemic) and that have also been determined to (ii) function like a corticosteroid or other immunosuppressive therapy, provide an opinion as to the likely total duration of the systemic therapy (e.g. less than 6 weeks during a 12-month period, 6 weeks or more, but not constantly, during a 12-month period, or constant or near-constant use during a 12 month period). See January 2011 VA treatment record. *The Appellant’s and Veteran’s statements should be considered. See September 2019 brief (asserting that the Veteran used systemic therapy for six weeks or more during a year and citing VA treatment records regularly listing prescriptions for both oral and topical antifungals and corticosteroids for skin conditions); see also November 2009 VA podiatry note; December 2010 Pharmacy note; January 2010 VA Podiatry note; June 2011 VA pharmacy note, March 2011 VA primary care physician note, January 2011 VA Pharmacy note; and January 2011 VA addendum treatment record. *A complete rationale should be provided for each conclusion. 2. Then, readjudicate the remanded claim on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harper, 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.