Citation Nr: 21009420 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 17-67 862 DATE: February 22, 2021 REMANDED Entitlement to service connection for a skin condition (claimed as a skin rash) as a result of exposure to herbicide agents is remanded. REASONS FOR REMAND The Veteran had active military service from February 1970 to February 1974. This claim was previously before the Board in October 2019 but was remanded for further development and consideration – including especially for a VA examination and medical opinion to ascertain all current skin disorders and their origin, particularly in terms of whether presumptively due to the Veteran’s service or, even if not, instead directly attributable to his service. Still more development of this claim is required, however. Entitlement to service connection for a skin disability again is remanded. The Veteran is claiming entitlement to service connection for a skin disorder that he initially described as a “rash”. The claims file includes an October 2020 Disability Benefits Questionnaire (DBQ) obtained following and as a result of the Board’s prior remand of this claim, which the Board finds is inadequate. Initially, the Board sees the examiner’s specialty is in internal medicine. Although a specialist is not needed in every situation, the Board finds that a dermatologist is better suited in this instance to differentiate between various skin diseases. Second, the examiner found that the Veteran had chloracne but failed to provide any adequate rationale for this diagnosis, especially given the extensive dermatology records that are unremarkable for chloracne, and VA’’s public health finding that chloracne appears within a year of toxic exposure, usually clears up within two years, and does not appear years later. Third, the examiner found that the Veteran had been diagnosed with chloracne in 1974; however, there are no clinical records associated with the claims file even indicating this. The examiner also stated that the Veteran was stationed in Thailand from 1970 to 1974, which is inaccurate (he served in Thailand from April to September 1973), and then states that no details were obtained about the onset of the current skin condition, which is contrary to the examiner’s assertion that the diagnosis was in 1974. When VA obtains an examination and opinion, it must they are adequate. According to 38 C.F.R. § 3.309(a)(6)(ii) chloracne warrants service connection on a presumptive basis due to exposure to an herbicide agent only if it manifests to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent. There is no competent and credible evidence of this in the file. In the prior October 2019 remand, the Board determined an examination was necessary because it was unclear what precisely was the diagnosis of the Veteran’s current skin disability. The October 2020 DBQ is inadequate in this regard as to a current diagnosis or in terms of explanation of why the diagnosis of chloracne is appropriate. Thus, the Veteran should be scheduled for another examination, preferably as mentioned with a dermatologist, to ascertain all current skin disorder diagnoses and to determine the likelihood any are causally related to the Veteran’s service, either as a disease presumptively associated with his service or alternatively as directly related to his service.   The Veteran’s service treatment records (STRs) reflect that he was seen in January 1971 for a small papule (boil) between his shoulder blades, and then seen again in March 1971 for acne on his face and furuncles on his back; he was advised to improve his hygiene. There are no further complaints of skin problems in his remaining three years of service. In addition, these two complaints were prior to his service in Thailand (which was in 1973), so prior to his claimed exposure to herbicide agents (including the dioxin in Agent Orange). The Veteran’s December 1973 Report of Medical History for separation purposes reflects that he denied having any skin diseases. Notably, he listed five other complaints that he had or had previously had, and an additional 11 conditions that he did not know if he had ever had. Thus, if he had chronic skin complaints at time of separation, it is entirely reasonable to assume he would have reported them. Essentially, the record reflects that he was willing to report complaints or ailments if he had them. See AZ v. Shinseki, 731 F.3d 1303, 1318 (Fed. Cir. 2013) (recognizing the widely-held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). Moreover, his corresponding December 1973 Report of Medical Examination for separation purposes reflects that his skin was normal upon evaluation. There are no clinical records for more than a decade after separation from service noting skin complaints. There are numerous private dermatology records from 1990 through 2011 noting skin conditions. For example, a November 1990 BJS dermatology record reflects that the Veteran had a one-year history of a rough lesion on the right zygoma and hyperpigmented lesions on his nose. He was advised to use sunscreen. He lived in Florida. An October 1992 record notes that a skin-check of his face, arms, back, and chest showed no abnormalities other than “AKs [actinic keratoses]” on his nose and temple, and a skin tag on his neck. He was strongly advised to use sunscreen. A November 1994 skin check reflects AKs and erythematous papular areas on his buttock and upper thighs; the impression was folliculitis. A November 1996 record notes multiple papula lesions on his scalp for one year, that the left zygoma bleeds at times for a year, and that the right zygomatic had been present for six months. He was diagnosed with irregular nevus, and the pathology report was negative for BCC (Basal Cell Carcinoma). A January 1998 record notes complaints of scaly lesions in an area (P.A.T.) for six months; he was examined for sun damage. These lesions were described as erythematous scaly patches and AKs. He also complained of a brown skin tag like lesion on his chest and neck area. In March 2001, the Veteran had a cystic lesion on his left mandible, scaly red lesions on his face, and a papular lesion on his neck; he was diagnosed with dermatitis. An October 2001 record notes four rough lesions on his nose that had been present for 3-4 months, In June 2003, he was diagnosed with BCC and AKs present for a few months. Additionally, the Veteran was diagnosed with suppurative granulomatous folliculitis (December 2004), benign hemangioma (May 2005), dysplastic junctional nevus with mild atypia (June 2006), compound dysplastic nevus with mild atypia (April 2007), squamous carcinoma (August 2007), AKs (August 2007), dermatophytosis of a few months in duration (December 2010), dysplastic compound nevus with mild atypia (January 2011), irritated seborrheic keratosis (February 2011), and lentiginous junctional melanocytic nevus (June 2011). If the Veteran has current skin disabilities (i.e., from 2012 to present), the examiner should provide an opinion on whether any is as likely as not causally related to the Veterans’ service. Accordingly, this claim is again REMANDED for the following still additional development and consideration: Schedule the Veteran for another examination – preferably with a dermatologist, if reasonably possible, to determine his current skin conditions and for an opinion on whether any condition confirmed to exist is as likely as not (50 percent or greater probability) causally related to his service.   In making these determinations, the examiner should consider the pertinent clinical evidence of record - to especially include: a.) the Veteran’s STRs noting a boil (January 1971), facial acne and back furuncles (March 1971), and a denial of skin diseases and a normal skin examination (December 1973); b.) private dermatology records from 1990 to 2011 (or more recent) noting the recent onset and diagnoses of various conditions to include: a rough lesion on the right zygoma, and hyperpigmented lesions on the nose (1990), AKs and a skin tag but no other abnormalities (October 1992), folliculitis on the buttock and upper thighs (November 1994), irregular nevus negative for BCC (November 1996), erythematous scaly patches, AKs, and a skin-tag like lesion (January 1998), dermatitis (March 2001), rough lesions on the nose (October 2001), BCC and AKs (June 2003), suppurative granulomatous folliculitis (December 2004), benign hemangioma (May 2005), dysplastic junctional nevus with mild atypia (June 2006), compound dysplastic nevus with mild atypia (April 2007), squamous carcinoma (August 2007), AKs (August 2007), dermatophytosis of a few months in duration (December 2010), dysplastic compound nevus with mild atypia (January 2011), irritated seborrheic keratosis (February 2011), and lentiginous junctional melanocytic nevus (June 2011); c.) the October 2020 DBQ noting a diagnosis of chloracne but not providing any rationale for this diagnosis; d.) the onset of any current (2012 to present) skin condition as supported by clinical records; and e.) the Veteran’s post-service employment as a letter carrier in Florida.   Any contention as to a rash since service is less than credible and should not be considered by the examiner. When responding, regardless of whether favorably or instead unfavorably, it is essential the examiner provide rationale – preferably citing to evidence in the file supporting conclusions and/or accepted medical authority. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Wishard 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.