Citation Nr: 21014857 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 15-17 510 DATE: March 15, 2021 REMANDED Entitlement to an initial compensable disability rating for service-connected eczema is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1983 to November 1996 and April 2005 to January 2012, with additional periods of reserves service. This case comes to the Board of Veterans’ Appeals (Board) on appeal from a November 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which is the Agency of Original Jurisdiction (AOJ). This appealed issue was previously before the Board in October 2018 and November 2020. On both occasions, the Board determined remands were necessary to obtain adequate medical examinations and opinions. The Board’s prior remand directives and the subsequent actions of the AOJ will be discussed below. The Veteran’s appeal has been returned to the Board for further appellate consideration. Entitlement to an initial compensable disability rating for service-connected eczema While further delay is regrettable, it is necessary in order to obtain an adequate medical opinion regarding the treatment of the Veteran’s eczema. Under the governing criteria, VA’s rating schedule evaluates skin disabilities such a eczema based on (1) the percentage of body (total and/or exposed areas) is affected by the disease and (2) principle treatment method utilized during the appeal period (i.e., whether the treatment regimen includes systemic therapy such as corticosteroids or other immunosuppressive drugs, and if so, for how long). Pursuant to the November 2020 Board remand, the Veteran received a new VA examination for his service-connected eczema in January 2021. The examiner addressed the questions presented in the November 2020 remand regarding the Veteran’s use of the prescribed Clobetasol and Triamcinolone to treat the Veteran’s eczema. However, the examiner noted that the Veteran discontinued these prescription medications during the last year in favor of using Lamisil to treat his eczema. The Federal Circuit addressed the meaning of “systemic” and “topical” for rating skin disabilities under the regulatory criteria prior to August 31, 2018. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). For these purposes, 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. Id. at 1355. The Federal Circuit acknowledged 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, but the Court emphasized that this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. Id. Rather, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the facts of each case. Id. at 1356. In Burton v. Wilkie, 30 Vet. App. 286 (2018), the Court found that the Board must consider the following two questions, in any order, when determining whether topical treatment for a skin disorder constitutes "systemic therapy such as corticosteroids or other immunosuppressive drugs" under the pre-August 13, 2018, version of DC 7806: (a) whether the topical treatment operates by affecting the body as a whole in treating a veteran's skin condition; and (b) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug. Only the second question needs to be considered if the treatment is clearly systemic Under the revised VA regulations, it is explicitly stated that for the purposes of the skin disability ratings, “systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin.” 38 C.F.R. § 4.118(a). As the record provides evidence of the use of Lamisil which was not discussed as a possible corticosteroid, a remand is necessary to obtain a medical opinion regarding whether the Veteran’s use of Lamisil in this case constitutes a systemic therapy, including a topical therapy administered on a systemic basis, or localized topical therapy, and if so, whether the Lamisil is a corticosteroid or immunosuppressive, or corticosteroid or immunosuppressive “like” drugs. The matters are REMANDED for the following action: Obtain an addendum opinion concerning the Veteran’s use of Lamisil to treat his service-connected eczema, as described in the January 2021 VA examination. Following a review of the claims file, including a copy of this remand, the examiner should provide the following opinions: (a.) Did the Veteran’s use of Lamisil operate by affecting the body as a whole in treating the service-connected eczema i.e. whether it is systemic therapy? (b.) If the Veteran’s use of Lamisil operated by affecting the body as a whole to treat the service-connected eczema, is Lamisil a corticosteroid or immunosuppressive drug, or a corticosteroid or immunosuppressive “like” drug? For purposes of the opinion, a topical corticosteroid or immunosuppressive may meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). The examiner is asked to provide a rationale for all opinions offered. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. W. Morgan, 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.