Citation Nr: 21014569 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 16-54 458 DATE: March 15, 2021 ORDER Service connection for residuals of a traumatic brain injury (TBI) is denied. Service connection for chronic sinusitis is denied. Service connection for a low back disorder is denied. An initial compensable rating for pseudofolliculitis barbae (PFB) is denied. REMANDED Entitlement to service connection for allergic rhinitis is remanded. Entitlement to service connection for a right eye disorder, to include as secondary to service-connected left eye disability, is remanded. Entitlement to service connection for a left ankle disorder is remanded. FINDINGS OF FACT 1. At no time during the pendency of the claim does the record contain a current disability of a TBI related to service, or residuals thereof, and the record does not contain a recent diagnosis of such a disability prior to the Veteran’s filing of a claim. 2. At no time during the pendency of the claim does the record contain a current disability of chronic sinusitis, and the record does not contain a recent diagnosis of such a disability prior to the Veteran’s filing of a claim. 3. A low back disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and arthritis did not manifest to a compensable degree within one year of discharge from active duty. 4. For the entire appeal period, the Veteran’s PFB’s has affected less than 5 percent of his entire body and exposed areas, has not required systemic therapy, and does not result in scarring or disfigurement. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a TBI have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for chronic sinusitis have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a low back disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for an initial compensable rating for PFB have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7813-7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1981 to May 1985. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in September 2015 and September 2016 by a Regional Office (RO) of the Department of Veterans Affairs (VA). In October 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In December 2018, the Board remanded the claims on appeal, as well as a claim for service connection for tinnitus, for additional development. While on remand, an April 2020 rating decision granted service connection for tinnitus. As such is a full grant of the benefit sought on appeal in regard to such issue, it is no longer before the Board. The remaining issues now return for further appellate review. The Board notes that, in February 2021, a VA Form 21-22a (Appointment of Individual as Claimant’s Representative) in favor of Falen LaPonzina, an attorney, was received. However, as the Veteran’s appeal was most recently certified to the Board and docketed in June 2020, and such change in representation was submitted more than 90 days thereafter without good cause, the Board finds that, at the current time, Kathy Lieberman, an attorney, retains representation of the Veteran in his appeal. 38 C.F.R. § 20.1305(a), (b); see e.g., Perez v. Shinseki, 25 Vet. App. 190 (2011) (the Board did not err in denying claimant’s request for change of representative, where request was submitted more than 90 days after his appeal was certified to the Board and no good cause was shown for the delay). The Board also observes that, subsequent to the issuance of the most recent supplemental statement of the case in April 2020, additional VA treatment records and unrelated VA examinations were associated with the record. However, in December 2020, the Veteran waived Agency of Original Jurisdiction (AOJ) consideration of such evidence. 38 C.F.R. § 20.1305(c). Further, in November 2020, the Veteran submitted additional evidence for consideration in his appeal. 38 U.S.C. § 7105(e)(1) (prior to February 19, 2019). Thus, the Board may properly consider the entirety of the evidence of record. Service Connection Claims Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as arthritis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Pertinent to a claim for service connection, such a determination requires a finding of a current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term “disability” means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term “disability” as used in 38 U.S.C. § 1110 “refers to the functional impairment of earning capacity, not the underlying cause of said disability,” and held that “pain alone can serve as a functional impairment and therefore qualify as a disability”). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the United States Court of Appeals for Veterans Claims (Court) held that the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a claimant filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for residuals of a TBI. The Veteran asserts he incurred a TBI during service when he struck his left eye on a ball at the end of a handle that covered up an elevator shaft, and residuals thereof, to include facial drooping and his already service-connected headaches. In this regard, the Veteran’s service treatment records reflect that, in June 1983, he sustained a soft tissue injury to his left eye area two weeks previously, but did not demonstrate any underlying damage to his eye structure. However, based on the Veteran’s reports of some numbness in the eye area (without visual impairment), he was reevaluated and the clinician assessed a contusion of the left eye. No further reference is made to such injury, to include a related loss of consciousness, and the Veteran was assessed as neurologically sound on his separation examination. While the Veteran has recently reported sustaining a loss of consciousness when sustaining his head injury, indicating a brain injury as opposed to facial trauma, the Board finds that, while he is competent to report such loss of consciousness, he is not shown to be a reliable historian when recounting his history of head trauma, thereby casting doubt on the veracity of his report. Specifically, such current report is contradicted by contemporaneous evidence of record that failed to document loss of consciousness. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (a lay person is competent to report symptoms based on personal observation when no special knowledge or training is required); Cromer v. Nicholson, 19 Vet. App. 215 (2005) (a history, provided by a veteran, that varied over time was not credible). Furthermore, while the Veteran denied any other head injuries while pursuing his claim for benefits, such report is likewise contradicted by the contemporaneous evidence of record. In this regard, during his December 2019 VA TBI examination, the Veteran stated that he sustained no head injuries other than his reported in-service head injury. However, in an April 2008 VA treatment record, he reported that he has been disabled since 2004 secondary to head trauma, noting a history of multiple falls with severe head trauma associated with each episode, resulting in secondary headaches and facial paralysis. Further, the Veteran’s prison treatment records document a June 2007 fall from the second floor to the first floor where he landed on his face and sustained a related loss of consciousness, and an August 2007 report of loss of consciousness. Moreover, when recounting the details of his in-service facial injury during a February 2012 Board hearing in conjunction with his claims for service connection for left eye and headache disorders, which was ultimately awarded as a result of such in-service facial trauma, the Veteran did not report sustaining any loss of consciousness, rather he recounted trauma only to his eye and soft tissue facial structures, and reported the subsequent development of headaches. Accordingly, given the lack of in-service documentation of the Veteran’s loss of consciousness, coupled with the evidence of record undermining his reliability as an accurate historian, the Board concludes that, while the evidence of record establishes that the Veteran incurred facial trauma during service, such does not establish that he incurred a TBI, resulting in any alteration of consciousness. Furthermore, post-service treatment records fail to suggest that the Veteran has any current residuals of his alleged in-service TBI, thereby failing to warrant service connection. In that regard, while he has been evaluated as having cognitive impairment prior to the current appeal period, such was not attributed to a head injury, but rather to human immunodeficiency virus (HIV)-related dementia. Indeed, the Veteran is currently in receipt of disability benefits from the Social Security Administration (SSA) based on his diagnosis of HIV in the mid-1990’s and HIV-related dementia, as diagnosed during a psychiatric assessment performed in December 2003. Specifically, in January 2004, the Veteran was awarded SSA disability benefits based on a primary diagnosis of HIV dementia and a secondary diagnosis of HIV. Likewise, a computerized topography (CT) study of the Veteran’s brain conducted in May 2008 and magnetic resonance imaging (MRI) studies of his brain performed in July 2010 and July 2016 revealed no abnormalities, to include evidence indicative of a TBI sustained during service nearly 40 years previously. Further, a December 2019 VA examiner determined that the Veteran did not incur a TBI during service. Specifically, she concluded that, based on contemporaneous service treatment records, the Veteran had not experienced any alteration of consciousness or reported any post-concussive amnesia, which, based on her clinical experience, would have suggested an injury of sufficient severity that it would have been recorded, especially such event did not occur during combat. Further, no cranial nerve abnormality was detected during the December 2019 VA cranial nerve examination. Rather, the VA examiner stated that the Veteran’s documented facial droop, which was not evident to the examiner at the time of the VA examination, was unlikely to have a neurological etiology based on the findings of his clinical neurological facial examination. Rather, the examiner opined that the Veteran’s mild facial assymetry was possibly a variant of normal. The Board affords great probative weight to the December 2019 VA examiner’s conclusion that the Veteran did not experience a TBI during service and has no current residuals thereof, as such conclusion considered all of the pertinent evidence of record, to include the statements of the Veteran and relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Further, the Board finds that the examiner’s conclusion is consistent with the Board’s own conclusion, namely that the Veteran’s recent report of having sustained a loss of consciousness during service lacks credibility. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Rather, the only TBI diagnosis of record is reflected in a September 2020 medical report from a private physician, Dr. A.A. While she opined that the Veteran does indeed have current residuals of an in-service TBI, including a facial droop and his service-connected headaches, she erroneously indicated that the Veteran’s service treatment records document a loss of consciousness. Further, Dr. A.A. did not examine the Veteran in conjunction with this medical opinion, or otherwise offer any clinical data (such as diagnostic imaging studies) to contradict the conclusion of the December 2019 VA examiner that the Veteran did not sustain a TBI during service and has no current residuals thereof. Rather, she cited the Veteran’s own reports of experiencing a loss of consciousness in service when sustaining his facial injury; however, as referenced above, his reports of this in-service loss of consciousness lack credibility. Thus, as his Dr. A.A.’s opinion is based on an inaccurate factual premise, it is entitled to no probative weight. See Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005); Coburn v. Nicholson, 19 Vet. App. 427, 432 (2006) (reliance on veteran’s statement renders a medical report not credible only if the Board rejects the statement of the veteran). Further, her opinion also fails to discuss the role that the Veteran’s documented post-service head traumas had on the development of his alleged residuals of an in-service TBI. Thus, for the foregoing reasons, the Board affords no probative weight to Dr. A.A.’s opinion. Moreover, the Veteran, as a lay person, is not competent to diagnose a TBI or relate any of his reported symptoms to such alleged in-service TBI. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran’s opinion as to the presence of a TBI, or residuals thereof, related to his military service is not competent evidence and, consequently, is afforded no probative weight. Based on the foregoing, the Board finds that at no time during the pendency of the claim does the record contain a current disability of a TBI related to service, or residuals thereof, and the record does not contain a recent diagnosis of such a disability prior to the Veteran’s filing of a claim. Accordingly, service connection for residuals of a TBI is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for residuals of a TBI. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 2. Entitlement to service connection for chronic sinusitis. The Veteran has sought service connection for both allergic rhinitis and chronic sinusitis, asserting he developed these disorders as a result of his in-service gas exposure. Specifically, he reports that during training, he entered a gas chamber while wearing a protective mask and was instructed to remove it once inside the gas chamber. He reports that this experience caused the immediate onset of nasal and sinus problems, which have persisted since that time. However, while the record shows a diagnosis of allergic rhinitis, the Veteran has not been diagnosed with chronic sinusitis at any time pertinent to the pendency of his claim. Specifically, no such diagnosis was rendered during his December 2019 VA otolaryngological examination as he did not report symptoms consistent with such a diagnosis. Further, while the Veteran’s treatment records during the appeal period reflects two instances of treatment for acute sinusitis, in February 2013 and January 2015, the remainder of such records fail to reflect a diagnosis of chronic sinusitis. Moreover, any references to chronic sinusitis in such records appear to be based on his reported history of such a diagnosis, rather than an independent clinical assessment as to the presence of such disorder. Furthermore, radiological imaging of the Veteran’s head has consistently failed to detect any sinus abnormalities indicative of chronic sinusitis. Furthermore, in recently submitted argument, the Veteran’s attorney did not reference sinusitis, but instead focused her arguments on the etiology of the Veteran’s diagnosed rhinitis. Similarly, the September 2020 opinion submitted by his attorney also does not reflect a diagnosis of sinusitis, and only notes the presence of rhinitis. Finally, the Veteran, as a lay person, is not competent to diagnosis such disorder as such requires medical expertise. See Jandreau, supra; Woehlaert, supra. As such, the Board finds that the record fails to demonstrate a current disability of chronic sinusitis during the pendency of the claim and, absent a diagnosis of the claimed disability, service connection may not be awarded. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 3. Entitlement to service connection for a low back disorder. The Veteran asserts that he developed his current low back disorder as a result of an in-service injury he sustained when he was pinned between the bulwark of his Naval vessel and a forklift. He reports that as a result of this injury, he developed low back pain and sought related treatment on two occasions during service. He further asserts that he has experienced low back pain since service, which he has primarily treated with non-prescription medications, and only sought treatment when the pain increased in severity over the years and became severe enough to trigger him to seek medical treatment. The Veteran’s service treatment records document two instances of treatment related to his low back in July and August of 1983. Specifically, in July 1983, he sought treatment for back pain that he had been experiencing for one day, and he was assessed as having a light back sprain. In August 1983, the Veteran sought treatment for upper left back pain, and was assessed as having a paraspinous muscle spasm. However, on his report of medical history at the time of his separation from service, he denied experiencing any recurrent back pain and his back was normal upon clinical evaluation. While the Veteran’s post-service treatment records, which date from 2001 to the present, reflect his reports of pain in various joints, including his neck, arm, shoulder, and right foot, the first reference to low back pain is recorded in a June 2013 VA treatment record. The Veteran was eventually diagnosed with lumbar spondylosis, as reflected in his private treatment records beginning in 2015, and as diagnosed at August 2016 and October 2019 VA examinations. As to the etiology of the Veteran’s low back disorder, the Board previously found the opinion rendered in conjunction with the August 2016 VA examination to be inadequate as it was not premised on a complete medical history, thereby necessitating a remand of this claim to obtain an adequate medical opinion. With regard to the three medical opinions obtained by the AOJ in response to the Board’s remand directives, all of which similarly fail to find a correlation between the Veteran’s current low back disorder and service, the Board finds that the most salient rationale is found in the February 2020 VA medical opinion, which explains that the Veteran’s current low back disorder, diagnosed as lumbar spondylosis, is an age-related spinal disorder that does not result from injury. As such, the VA examiner concluded that the Veteran’s current back disability cannot be related to his in-service back complaints and any related injury. Further, the Board finds that this medical opinion and related rationale are consistent with the Veteran’s statements that his back impairment was not significant enough to warrant seeking professional treatment for many years after service, as reflected by his first reports of low back pain to his post-service treatment providers in 2013. This medical opinion also negates a theory that the Veteran’s current low back disorder, which is a degenerative disease/form of arthritis, could have manifested to a compensable degree within one year of the Veteran’s separation from service, as the disease is age-related and as such, manifested many years after service. The Board affords great probative weight to the February 2020 VA examiner’s opinion, as such considered all of the pertinent evidence of record, to include the statements of the Veteran and relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Notably, there is no medical opinion to the contrary. As to the argument of the Veteran’s attorney that the VA medical opinions of record fail to consider all of the Veteran’s in-service back treatment, to specifically include treatment in December 1984 for an episode of back pain. However, as no such in-service documentation of back treatment exists, the Board presumes the attorney was confusing the Veteran’s December 1984 treatment for right foot pain (discussed in the context of the VA opinion regarding the etiology of his left ankle disorder) with other in-service back treatment. Moreover, the February 2020 VA opinion cited above considers both of the Veteran’s documented in-service back treatment records, which are dated in July and August of 1983. Therefore, based on the foregoing, the Board finds a low back disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and arthritis did not manifest to a compensable degree within one year of discharge from active duty. Thus, service connection for such disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection for a low back disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra Increased Rating Claim 4. Entitlement to an initial compensable rating for PFB. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The Veteran is in receipt of a noncompensable rating for his service-connected PFB, a medical condition affecting his face and neck caused by chronic inflammation resulting from ingrown hairs resulting from shaving, as of June 20, 2016, the date of service connection. The Veteran appears to assert that the chronic and active nature of his PFB warrants the assignment of a compensable (10 percent or higher) rating, and his attorney asserts that the scarring and disfigurement from his PFB warrant the assignment of a compensable rating. The Veteran’s service-connected PFB has been evaluated pursuant to the Diagnostic Code 7813 and 7806, as in effect prior to August 13, 2018, which outline the rating criteria for dermatophytosis and dermatitis or eczema, respectively. Per Diagnostic Code 7813, disabilities evaluated under this rating criteria should be evaluated pursuant to Diagnostic Codes 7800 through 7806, depending on the predominant disability. While the Veteran’s attorney has asserted that the Veteran should be awarded a compensable rating for his PFB as a result of related scarring and disfigurement, described as abnormal skin texture and hypo- or hyperpigmentation, the Veteran has not reported that his PFB has resulted in such impairments (disabilities evaluated by Diagnostic Codes 7800 through 7805), and the clinicians who conducted his August 2016 and September 2019 VA dermatological examinations stated that there was no evidence of such scarring or disfigurement. As such, the Board finds that the Veteran’s PFB is most appropriately rated pursuant to Diagnostic Code 7806, which outlines the rating criteria for dermatitis and eczema. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable evaluation is warranted for dermatitis or eczema where there less than 5 percent of the entire body or less than 5 percent of exposed areas are affected, and no more than topical therapy is required during the past 12-month period. A 10 percent evaluation is warranted for dermatitis or eczema affecting at least 5 percent, but less than 20 percent of the entire body or of the exposed areas, or requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation is warranted for dermatitis or eczema affecting 20 percent to 40 percent of the entire body or of the exposed areas, or requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum 60 percent evaluation is warranted for dermatitis or eczema affecting 40 percent of the entire body or more than 40 percent of the exposed areas, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. See 38 C.F.R. § 4.118, Diagnostic Code 7806. As of August 13, 2018, Diagnostic Code 7806 provides that dermatitis is rated under the General Rating Formula for the Skin. In this regard, such provides for a noncompensable rating where there is characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected; or no more than topical therapy required over the past 12-month period. A 10 percent rating is warranted where there is characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, 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 assigned where there is characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or 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 60 percent rating is warranted where there are characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or 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. Under the new criteria, a note preceding 38 C.F.R. § 4.118 provides that, for the purposes of this section, “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.” With regard to the meaning of “systemic therapy” prior to the new definition of the term in the revised criteria, the United States Court of Appeals for Veterans Claims (Court) in Johnson v. McDonald, 27 Vet. App. 497, 505 (2016) held that use of a topical steroid constituted “systemic therapy” within the meaning of Diagnostic Code 7806. In Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the Federal Circuit reversed this decision and determined that “constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs” under Diagnostic Code 7806 is generally not inclusive of topical corticosteroids. The Federal Circuit found that “systemic therapy” means “treatment pertaining to or affecting the body as a whole,” whereas topical therapy means “treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.” Thus, according to the Federal Circuit, all applications of topical corticosteroids do not constitute systemic therapy. The Federal Circuit also held that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Burton v. Wilkie, 30 Vet. App. 286 (2018), the Court held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. During the appeal period, the Veteran underwent VA dermatological examinations in August 2016 and September 2019, during which his PFB as assessed as affecting less than 5 percent of both his entire body and his exposed areas. The Board finds that the examiner’s findings are consistent with the Veteran’s reports that his PFB affects his lower face and neck. As such, an increased rating on the basis of how much of his body or exposed areas are affected by his PFB is not warranted. As to whether the Veteran may be entitled to an increased rating based on his use of a systemic therapy to treat his PFB, during his August 2016 examination, he reported using the topical corticosteroid Desonide to treat his PFB, as well as a non-corticosteroid topical medication, Tretinoin 0.05%, and, during his September 2019 examination, he reported using only Desonide, applied prior to shaving. Based on his reported frequency of use during these examinations, the 2016 and 2019 VA examiners both stated that the Veteran used his topical PFB medications for less than 6 weeks of the past 12 months. However, the Veteran’s topical corticosteroid use cannot be deemed systemic in nature, as such treatment was only administered to his face and neck, i.e., the areas affected by PFB. Therefore, such topical corticosteroid treatment would not be used on a scale sufficient to affect the entire body and thus qualify as systemic, and the Veteran cannot be awarded a compensable rating based on the use of systemic therapy to treat his PFB. Based on the foregoing, the Board an initial compensable rating for PFB pursuant to Diagnostic Code 7806 is not warranted. In reaching such determination, the Board acknowledges the Veteran’s report that his PFB is painful and remains present even when he does not shave. However, absent a finding that the Veteran’s PFB causes scarring, there is no basis for awarding a compensable rating based on the reports that his PFB is persistent and painful. The Board has also considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran’s service-connected PFB; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Further, neither the Veteran nor his attorney have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the initial rating claim adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Therefore, based on the foregoing, the Board finds that the preponderance of the evidence is against the Veteran’s claim for an initial compensable rating for PFB and, accordingly, there is no doubt to be resolved and such must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 5. Entitlement to service connection for allergic rhinitis. When perfecting his appeal of his claim seeking service connection for allergic rhinitis, the Veteran reported that he used non-prescription medications such as Actifed, a combination antihistamine and decongestant, and Sudafed, a decongestant, during service to treat his allergic rhinitis symptoms, which was recently reiterated in argument submitted by the Veteran’s attorney. The Board notes that the Veteran’s service treatment records do indeed document his treatment for an adverse reaction to Sudafed, although no reference is made in regard to why he was taking this medication. However, when rendering December 2019 opinion that the Veteran’s allergic rhinitis is unrelated to service, the VA examiner cited the lack of documentation of any allergic rhinitis symptoms during service, but did not consider whether the Veteran was taking Sudafed to treat such symptoms. Moreover, when rendering the September 2020 opinion that the Veteran’s allergic rhinitis had its onset during service, Dr. A.A. failed to reconcile the Veteran’s recent report of continuity of allergic rhinitis symptoms since service with the post-service treatment records documenting of his report of recent, post-service onset of his symptoms. Accordingly, both the VA and private medical opinions addressing the etiology of the Veteran’s allergic rhinitis are legally inadequate, and a new opinion addressing the etiology of his current allergic rhinitis, predicated on an accurate and complete medical history, must be obtained. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). 6. Entitlement to service connection for a right eye disorder, to include as secondary to service-connected left eye disability. The Veteran asserts that he developed a right eye disorder, either as a result of the same in-service injury during which he incurred a left eye injury (resulting in his service-connected left eye disability) or as secondary to such service-connected disability. The Veteran’s service treatment records fail to reference any right eye impairment, including when he was treated for his left eye injury; however, during his Board hearing, he testified that he believed that he developed his right eye glaucoma as a result of such in-service left injury or as a result of his traumatic left eye glaucoma. Indeed, in September 2020, Dr. A.A. stated that the Veteran had developed right eye glaucoma as a result of his service-connected traumatic left eye glaucoma. However, notably, while the AOJ has referred to the Veteran’s service-connected left eye disability as encompassing glaucoma, the record fails to reflect that the Veteran has been diagnosed with glaucoma of either eye. Rather, all ophthalmological clinical evaluations during the appeal period have resulted only in diagnoses of “glaucoma suspect,” with no evidence of traumatic glaucoma. Furthermore, as Dr. A.A. did not examine the Veteran, her reference to the diagnosis of glaucoma is not based on any supportable clinical evidence. Rather, the only right eye diagnoses rendered during the appeal period are dry eye syndrome, age-related cataracts, and refractive errors, the latter of which is not eligible for service connection absent evidence of a superimposed disease or injury during service that resulted in additional disability. With the exception of the Veteran’s age-related cataracts, the medical opinions of record do not adequately address the etiology of his current right eye disorders of dry eye syndrome and refractive errors, to include whether the Veteran’s left eye injury constitutes a superimposed in-service injury that resulted in additional disability. Accordingly, a remand is required to obtain such medical opinions. See id. 7. Entitlement to service connection for a left ankle disorder. The Veteran asserts that he developed a left ankle disorder as a result of the aforementioned in-service forklift injury, spurring him to seek treatment for left ankle pain on two occasions in May 1984. In that regard, the record reflects that on May 23,1984, the Veteran sought treatment for a sore left ankle, and he was assessed with a mild left ankle sprain, and on the following day, May 24, 1984, he reported that his ankle pain had improved, and he was again assessed with mild left ankle sprain. The Veteran did not report any ankle impairment on separation from service, and his lower extremities were assessed as normal on clinical evaluation on his separation medical examination. The Veteran’s post-service treatment of record, which spans from 2001 to the present, first references left ankle pain in February 2016. However, no clinical diagnosis of a left ankle disorder is reflected in those treatment records, and no left ankle diagnoses were rendered in conjunction with August 2016 and October 2019 VA examinations. However, while the examination of the Veteran’s left ankle was completely normal in 2016, the 2019 examiner found that such impacted his ability to work. In this regard, examination revealed 10 degrees of loss of plantar flexion and pain evidenced on dorsiflexion and the Veteran reported functional impairment described as pain with weight-bearing that limited his ability to stand and walk. The Board finds this evidence of a functional impairment sufficient for establishing a left ankle disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018) (holding that pain alone may constitute a disability, even without an identifiable underlying pathology, provided that such pain is productive of functional impairment). However, given that the VA medical opinions of record are largely predicated on the lack of a discernable left ankle disability, there is no cogent opinion of record addressing whether the Veteran’s current left ankle disability is attributable to his military service, to include his documented in-service treatment for left ankle pain. Thus, a remand is necessary in order to obtain an addendum opinion addressing such matter. See Barr, supra. The matters are REMANDED for the following action: 1. Obtain a VA medical opinion from an appropriate clinician regarding whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s current allergic rhinitis is related to service. Specifically, the clinician is asked to consider the Veteran’s reports that he used the non-prescription medications such as Actifed, a combination antihistamine and decongestant, and Sudafed, a decongestant, during service to treat his allergic rhinitis symptoms, as well as the April 1983 service treatment record noting the Veteran’s symptoms for a possible adverse reaction to Sudafed. The clinician should also consider the Veteran’s first documented diagnosis of allergic rhinitis is reflected in a July 2015 VA treatment records, with the Veteran reporting the relatively recent onset of his symptoms during July 2016 VA otolaryngological treatment. A rationale for any opinion offered should be provided. 2. Obtain a VA medical opinion from an appropriate clinician regarding whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s current right dry eye syndrome is related to his military service, to include his documented in-service facial trauma in June 1983, caused by his service-connected left eye disability, or aggravated by his service-connected left eye disability. Further, with regard to the Veteran’s diagnosed right eye refractive error, the clinician is asked to offer an opinion as to whether such was subject to a superimposed disease or injury during service, to include his documented in-service facial trauma in June 1983, that resulted in additional disability. If so, please identify the additional disability. A rationale for any opinion offered should be provided. 3. Obtain a VA medical opinion from an appropriate clinician regarding whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s current left ankle disability, as reflected by functional impairment of earning capacity at the October 2019 VA examination, is related to service, to include his reported forklift accident and/or his documented in-service complaints of left ankle pain in May 1984. In this regard, the examiner is advised that, while the Veteran may not have a current diagnosis of a left ankle disorder, he or she should accept that he has a left ankle disability for VA purposes. Specifically, the clinician is also asked to consider the Veteran reports of experiencing left ankle pain since service which he self-medicated with over the counter medications, but his ankle pain was not of sufficient severity to warrant mentioning to his treatment providers until February 2016, which reflects the first post-service reference to left ankle pain of record. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Northcutt, 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.