Citation Nr: 21011414 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 15-14 518A DATE: March 1, 2021 REMANDED Entitlement to a rating in excess of 10 percent for pseudofolliculitis barbae (PFB) with residuals of acne vulgaris prior to March 23, 2019, and in excess of 30 percent, thereafter, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from January 1969 to March 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board finds that remand is warranted for additional development. Entitlement to a rating in excess of 10 percent for PFB with residuals of acne vulgaris prior to March 23, 2019, and in excess of 30 percent, thereafter, is remanded. In the January 2020 remand, the Board directed the RO to first obtain outstanding private and VA medical center (VAMC) treatment records concerning the Veteran’s treatment for his skin. As required by 38 C.F.R. § 3.159, the Veteran provided the VA with enough information to obtain the private treatment records by submitting multiple General Release for Medical Provider Information forms. One such release was for Baptist Primary Care. Although a request was made to the private provider in March 2020, the private provider provided a response in April 2020, notifying the RO that the authorization required the Veteran’s signature. No subsequent action took place after this notification. If VA receives information showing that subsequent requests could result in obtaining the private records sought, then reasonable efforts include at least one follow-up request to the new source or an additional request to the original source. 38 C.F.R. § 3.159. Thus, the Board first finds that the RO is not in substantial compliance with the January 2020 Board remand and additional efforts must be undertaken to obtain these outstanding records. Stegall v. West, 11 Vet. App. 268, 271 (1998). Additionally, in March 2020, the Veteran informed the RO of his treatment at the Boston VAMC records from October 2005 to June 2016. However, the record reflects that only his Boston VAMC records from July 2001 to February 2007 are associated with the claims file. VA will make as many requests as are necessary to obtain relevant records from a Federal department or agency. 38 C.F.R. § 3.159. The record does not reflect that subsequent attempts were made to obtain the outstanding Boston VAMC treatment records. The Veteran also indicated in a September 2020 written statement that he has been prescribed medications, to include Aczone, for his service-connected skin condition. He contested a recent April 2020 VA examiner’s opinion indicating hat his Aczone was only prescribed for his service-connected chloracne and that the Veteran, on his own, also used the medication for his PFB. The Veteran relayed that he used Aczone, along with the other medications, as directed and prescribed by his private dermatologist, Dr. B.J., and submitted April and August 2019 private treatment records from Dr. B.J. to support his assertion. The April 2020 VA addendum opinion, in which the examiner opined that the Aczone has not been prescribed for the Veteran’s PFB, does not adequately address the Veteran’s contentions of continued and updated medication for his disability and, along with the other medical evidence, does not clearly indicate whether any of the Veteran’s other medications are prescribed for his PFB. VA’s duty to assist a Veteran includes providing such thorough and contemporaneous examination when the record does not adequately reveal the current state of the Veteran’s disability. Hart v. Mansfield, 21 Vet. App. 505, 508 (2007). Thus, in light of the foregoing, a new VA examination is warranted to assess the current nature and frequency of any prescribed treatment for his disability, as well as the current severity of his PFB. The matter is REMANDED for the following action: 1. Obtain any outstanding private and VAMC treatment records concerning skin treatment, including the Baptist Primary Care treatment records, treatment records from private dermatologist Dr. B.J., and the Boston VAMC treatment records from February 2007 to June 2016. If identified records are not ultimately obtained, the Veteran should be notified pursuant to 38 C.F.R. § 3.159. 2. After the above development is complete, schedule an examination to assess the severity level of the Veteran’s PFB. The claims file and a copy of this remand must be made available for review, and the examination report must reflect that review of the claims file occurred. An in-person examination may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. In doing so, the Board is specifically interested in any treatment the Veteran specifically is prescribed for his PFB, how often he uses the medication, whether the treatment is a systemic therapy or is like a corticosteroid or immunosuppressive drug, such as but not limited to the listed medications of Olux, Emla, Aczone, Doxycycline, and Clobetasol. No examination of his scars related to PFB is necessary. (Continued on the next page) A complete rationale should be provided for any opinion rendered. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Q. Alli, Associate 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.