Citation Nr: 21015020 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 15-01 349 DATE: March 16, 2021 ORDER Entitlement to a 30 percent initial rating, and no higher, for tension headaches, prior to November 4, 2019, is granted. Entitlement to an initial disability rating in excess of 30 percent for tension headaches, from November 4, 2019, is denied. Entitlement to a 10 percent initial rating, and no higher, for left leg varicose veins prior to November 4, 2019, is granted. Entitlement to an initial rating in excess of 20 percent for left leg varicose veins from November 4, 2019, is denied. Entitlement to a 10 percent initial rating, and no higher, for right hip scars prior to November 4, 2019 is granted. Entitlement to an initial disability rating in excess of 20 percent for right hip scars from November 4, 2019 forward is denied. Entitlement to an initial disability rating in excess of 10 percent for left hip scars is denied. REMANDED The issue of entitlement to an initial compensable rating for herpes simplex, type I, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to from April 9, 2014, from October 1, 2015 to October 20, 2015, and from December 1, 2016 forward is remanded. FINDINGS OF FACT 1. During the relevant period prior to November 4, 2019, the Veteran’s headaches manifested in characteristic prostrating attacks occurring on an average once a month over last several months, but were not very frequent, completely prostrating, prolonged, and productive of severe economic inadaptability. 2. During the period beginning November 4, 2019, the Veteran’s tension headaches manifested in characteristic prostrating attacks occurring on an average once a month over last several months, but were not very frequent, completely prostrating, prolonged, and productive of severe economic inadaptability. 3. Prior to November 4, 2019, the Veteran’s left leg varicose veins manifested in intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery. 4. From November 4, 2019, the Veteran’s left leg varicose veins did not manifest in persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. 5. The record shows that, prior to November 4, 2019, the Veteran’s service-connected right hip scars were painful. 6. From November 4, 2019, the Veteran’s service-connected right hip scars are not manifested by five or more scars that are unstable or painful. 7. The Veteran’s service-connected left hip scars are not manifested by three or four scars that are unstable or painful. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 30 percent initial rating, prior to November 4, 2019, for tension headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.14, 4.21, 4.124a, Diagnostic Code 8100. 2. The criteria for entitlement to an initial rating in excess of 30 percent, from November 4, 2019, for tension headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.14, 4.21, 4.124a, Diagnostic Code 8100. 3. The criteria for entitlement to a 10 percent initial rating, prior to November 4, 2019 for left leg varicose veins have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7120. 4. From November 4, 2019, the criteria for entitlement to an initial rating in excess of 20 percent for left leg varicose veins have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7120. 5. The criteria for entitlement to a rating of 10 percent for right hip scars prior to November 4, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.118, Diagnostic Code 7804. 6. The criteria for entitlement to a rating in excess of 20 percent for right hip scars from November 4, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.118, Diagnostic Code 7804. 7. The criteria for entitlement to a rating in excess of 10 percent for left hip scars have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.118, Diagnostic Code 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1990 to June 2011. These matters come before the Board of Veterans’ Appeals (Board) on appeal of a July 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously remanded by the Board in August 2018. A review of the claims file shows that there has been substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The case has been returned to the Board for review. In a March 2020 rating decision, the Agency of Original Jurisdiction (AOJ) increased the rating for the Veteran’s tension headaches to 30 percent, effective November 4, 2019; increased the rating for his varicose veins, left leg, to 20 percent, effective November 4, 2019; granted service connection for painful scars, right hip with a 20 percent evaluation, effective November 4, 2019; and granted service connection for painful scars, left hip, with a 10 percent evaluation effective November 4, 2019. As the increase did not satisfy the appeal in full, the issues remain on appeal and has been characterized as shown on the title page of this decision. See AB v. Brown, 6 Vet. App. 35 (1993). The Board is cognizant that the United States Court of Appeals for Veterans Claims (Court) has held that a claim for a TDIU, either expressly raised by the Veteran or reasonably raised by the record, is part of the claim for an increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran has asserted that he is unable to work due to his service-connected disabilities, and therefore the issue of entitlement to a TDIU is on appeal. The Veteran is in receipt of a combined 100 percent rating from April 9, 2014 to October 1, 2015, and from October 20, 2015 forward. However, the receipt of a combined 100 percent schedular rating does not render the issue of entitlement to a TDIU moot where the award of a TDIU based on a single disability may result in the Veteran being eligible for higher levels of compensation, specifically special monthly compensation at the housebound rate under 38 U.S.C. § 1114(s). Bradley v. Peake, 22 Vet. App. 280 (2008); Buie v. Shinseki, 24 Vet. App. 242 (2010). In this case, the Veteran has been awarded SMC pursuant to 38 U.S.C. § 1114(s) for the periods from April 9, 2014 to October 1, 2015 and from October 20, 2015 to December 1, 2016. As such, the issue of entitlement to a TDIU during these periods is moot. However, the issue of entitlement to a TDIU is not moot for the balance of the period on appeal. However, in this case the Veteran is rated as 100 percent disabled and is in receipt of SMC payable at the housebound rate under 38 U.S.C. § 1114(s). Therefore, the award of a TDIU would result in no further benefit, the issue of entitlement to a TDIU is rendered moot, and the Board need not consider the issue of entitlement to a TDIU. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). The Board notes that in their February 2021 appellate brief the Veteran’s representative argued that the issues of entitlement to increased ratings for seborrheic dermatitis, a staph infection, hemorrhoids and eczema were not addressed in the March 2020 supplemental statement of the case despite being part of the current appeal. However, The rating decision assigning the ratings for these disabilities was issued under modernized review system created by the Appeals Modernization Act (AMA), and therefore the ratings assigned in that decision may only be appealed pursuant to the AMA. 38 C.F.R. § 3.2400, 19.2(d). A review of the record shows that the Veteran has not otherwise at any point perfected an appeal of the ratings assigned for those disabilities to the Board. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). While the issue of entitlement to service connection for seborrheic dermatitis was before the Board in August 2018, the Board granted service connection for that disability, which constituted a full grant of the benefits sought and thus resolved the appeal before the Board. Ab v. Brown, 6 Vet. App. 35 (1993). As such, the Board finds that the issues noted in the February 2021 appellate brief are not properly before the Board, and will not address them further. Increased Ratings Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). 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. Where there is a question as to which of two 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). 1. Entitlement to higher initial ratings for tension headaches The Veteran seeks higher initial ratings for his service-connected tension headaches. The Veteran’s service-connected tension headaches are rated as noncompensable prior to November 4, 2019, and 30 percent disabling, from November 4, 2019, under 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under Diagnostic Code 8100, a noncompensable rating is warranted for headaches with less frequent attacks. A 10 percent rating is warranted for headaches with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is warranted for headaches with characteristic prostrating attacks occurring on an average once a month over last several months. A 50 percent rating is warranted for headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The rating criteria of Diagnostic Code 8100 are considered successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). This renders 38C.F.R. §§ 4.7 and 4.21 inapplicable. Id. at 252. The phrase “characteristic prostrating attacks” is used in the criteria corresponding to 10 percent and 30 percent ratings under Diagnostic Code 8100 to describe the nature and severity of headaches, but it is not defined in the regulation. Pursuant to Dorland’s Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as “extreme exhaustion or powerlessness.” Thus, the phrase “characteristic prostrating attacks” is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness. The rating criteria for a 50 percent rating include several undefined phrases. The descriptive phrase “very frequent” connotes a frequency at least greater than once a month, as is required by the rating criteria corresponding to a lesser 30 percent rating. Johnson, 30 Vet. App. at 253. The phrase “completely prostrating” generally means that the migraines attack must render the veteran entirely powerless. Id. The completely prostrating attacks must also be “prolonged,” which is defined as “to lengthen in time: extend duration: draw out: continue, protract.” Id. (internal citation omitted). Lastly, the 50 percent rating criteria requires that the very frequent completely prostrating and prolonged attacks be “productive of severe economic inadaptability.” Productive can be read as having either the meaning of “producing” or “capable of producing,” and, with regard to severe economic inadaptability, nothing in Diagnostic Code 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004). For the period prior to November 4, 2019, the Board concludes that the record shows a 30 percent initial rating was warranted. Specifically, an April 2011 VA examination reflects that the Veteran had pain in the back of his head that required him to stay in bed and not do anything. He reported experiencing headaches three to four times per week that last for two hours. The Veteran reported that when the headaches occur, he has to stay in bed. The Board finds that the April 2011 VA examination reflects that the Veteran met the criteria for a 30 percent rating under Diagnostic Code 8100, as he had characteristic prostrating attacks occurring on an average of at least once a month over last several months. With regard to the issue of a rating in excess of 30 percent during the entire period on appeal, the Board concludes that the criteria for a higher 50 percent rating are not met. The record does not show that the Veteran’s headaches rendered him entirely powerless for prolonged periods. Specifically, a November 2019 VA examination, reflects headache symptoms of constant head pain, pulsating or throbbing head pain, pain on both sides of the head and pain worsening with physical activity. Additionally, the Veteran reported non-headache symptoms of nausea, vomiting, sensitivity to light, and sensitivity to sound. The VA examiner characteristic prostrating attacks of migraine/non-migraine headache pain more than once per month. The VA examiner noted that the Veteran’s prostrating attacks are not productive of severe economic inadaptability. As such, the record does not show that the Veteran’s headaches rendered him entirely powerless for prolonged periods. In summary, the Veteran’s headaches met the criteria for a rating of 30 percent prior to November 4, 2019. However, the Veteran’s headaches did not meet the criteria for a rating in excess of 30 percent for the entire period on appeal. To the extent that the Veteran seeks ratings for tension headaches higher than those awarded in this decision or previously awarded, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to higher initial ratings for left leg varicose veins. The Veteran seeks higher initial ratings for his service-connected varicose veins, left leg. The Veteran’s service-connected varicose veins, left leg, is rated as noncompensable prior to November 4, 2019, and 20 percent disabling from November 4, 2019 under 38 C.F.R. § 4.104, Diagnostic Code 7120. Under Diagnostic Code 7120, a 10 percent rating is assigned for intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking with symptoms relieved by elevation of extremity or compression hosiery. A 20 percent rating is assigned for persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema. A 40 percent rating is assigned for persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 60 percent rating is assigned for persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. A 100 percent rating is assigned for massive board-like edema with constant pain at rest. For the period prior to November 4, 2019, the Board concludes that the record shows a 10 percent initial rating was warranted. Specifically, an April 2011 VA examination reflects that the Veteran reported edema with partial relief when his lower extremity is elevated. He further reported pain, aching and fatigue at rest. Additionally, the Veteran reported difficulty walking. The Board finds that the April 2011 VA examination reflects that the Veteran met the criteria for a 10 percent rating under Diagnostic Code 7120, as he demonstrated intermittent edema of extremity. A rating in excess of 10 percent, prior to November 4, 2019, is not warranted since the Veteran did not demonstrate persistent edema, incompletely relieved by elevation or extremity, with or without beginning stasis pigmentation or eczema. As for the period after November 4, 2019, the Board finds that a rating in excess of 20 percent is not warranted. Specifically, at a November 2019 VA examination, the VA examiner noted aching and fatigue after prolonged standing and walking. The VA examiner further noted persistent edema that is completely relieved by elevation of extremity. The Veteran did not demonstrate stasis pigmentation or eczema. The Veteran noted he uses compression stockings prescribed for his left leg varicose veins. Having reviewed the complete record, the Board finds that the evidence does not support the criteria for a disability rating in excess of 20 percent from November 4, 2019, for varicose veins, left leg, under Diagnostic Code 7120. The evidence shows no evidence of persistent edema and stasis pigmentation or eczema. In making its determinations in this case, the Board has carefully considered the Veteran’s contentions with respect to the nature and severity of his service-connected varicose veins, left leg, at issue, and notes that his lay testimony is competent to describe certain symptoms associated with this disability. The Veteran’s history and symptom reports have been considered, including as presented in the medical evidence discussed above, and are noted to be contemplated by the criteria for the disability rating for which the Veteran has been found entitled by the Board. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability at issue. As such, while the Board accepts the Veteran’s statements with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected condition at issue. In summary, the Veteran’s varicose veins, left leg, met the criteria for a rating of 10 percent, and no higher, prior to November 4, 2019. However, the Veteran’s varicose veins, left leg, did not meet the criteria for a rating in excess of 20 percent, from November 4, 2019. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy, 27 Vet. App. at 495; Doucette, 38 Vet. App. at 369-70. To the extent that the Veteran seeks ratings for varicose veins, left leg, higher than those awarded in this decision or previously awarded, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to higher initial ratings for service-connected scars The Veteran seeks higher initial ratings for his service-connected scars. Prior to November 4, 2019, the Veteran’s service-connected scars are rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7805. The Veteran’s scars were rated as noncompensable since July 1, 2011, the day following his separation from active service. As noted above, in a March 2020 rating decision the RO granted service connection for painful scars, right hip with a 20 percent evaluation, effective November 4, 2019; and granted service connection for painful scars, left hip, with a 10 percent evaluation effective November 4, 2019. The Veteran’s bilateral hip scars are rated under 38 C.F.R. § 4.118, Diagnostic Code 7804. Prior to November 4, 2019, the Veteran’s scars are rated together as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7805. Also relevant to the current appeal is 38 C.F.R. § 4.118, Diagnostic Code 7804, which provides ratings for unstable or painful scars. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7804 was not changed by the August 13, 2018 amendments. Under Diagnostic Code 7804, one or two scars that are unstable or painful warrants a 10 percent rating. Three or four scars that are unstable or painful warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. The Veteran was provided a VA examination in April 2011. The VA examiner reported that the Veteran had one 8.0 cm by 0.3 cm scar on his left hip, one 23.0 cm by 0.3 cm scar on his right hip and one 5.0 cm by 0.2 cm scar on his right middle finger. The VA examiner reported that the Veteran’s scars were not painful on examination. However, during the examination, the Veteran reported that his right hip scar causes pain and numbness. As such, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s right hip scar was painful, prior to November 4, 2019, such that a rating of 10 percent is warranted under Diagnostic Code 7804. Prior to November 4, 2019, the Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran’s service-connected scars were not of the head, face, or neck, were not deep and nonlinear, and were not associated with underlying soft tissue damage. The scars also did not cover an area or areas of 144 square inches or greater. Therefore, Diagnostic Codes 7800 through 7802, prior to November 4, 2019, are inapplicable. Finally, the evidence of record shows there are no other disabling effects not considered in a rating provided under Diagnostic Codes 7800 through 7804 as contemplated under both pre- and post-August 13, 2018 Diagnostic Code 7805. As to the period from November 4, 2019, the Veteran is in receipt of a 20 percent rating for painful scars – right hip S/P total hip replacement and a 10 percent rating for painful scars – left hip S/P total replacement under 38 C.F.R. § 4.118, Diagnostic Code 7804. Turning to the relevant evidence of record, the November 2019 VA examiner noted a single scar on the Veteran’s right middle finger. The scar was nontender, linear, and measured 7.2 centimeters by 0.1 centimeters, which is a total area of 0.72 square centimeters. The VA examiner noted three scars on the Veteran’s right lower extremity. The first scar was tender, linear, and measured 8.5 centimeters by 0.1 centimeters. The second scar was tender, linear, and measured 23.5 centimeters by 0.1 centimeters. The third scar was tender, linear, and measured 14.0 centimeters by 0.1 centimeters, which is a total area of 4.6 square centimeters. All three scars were tender to palpation. The VA examiner noted two scars on the Veteran’s left lower extremity. The fist scar was tender, linear and measured 10.0 centimeters by 0.1 centimeters. The second scar was tender, linear, and measured 14.0 centimeters by 2.0 centimeters, which is a total area of 29.0 square centimeters. Both scars were tender to palpation. Accordingly, the relevant medical evidence of record indicates that, from November 4, 2019, the Veteran’s scars of the right middle finger and bilateral lower extremity were linear. As such, Diagnostic Codes 7800 through 7802 are not for application. The Veteran had one painful scar on his right middle finger that was nontender and not painful. Under Diagnostic Code 7804, a single scar that is not painful and not unstable does not warrant a compensable rating. As such, the Veteran is not entitled to a compensable rating for his right middle finger scar. The Veteran had three scars on his right hip that were painful and not unstable. Under Diagnostic Code 7804, three or four scars that are unstable or painful warrants a 20 percent rating. The Veteran had two scars of the left hip that were painful and not unstable. Under Diagnostic Code 7804, one or two scars that are unstable or painful warrants a 10 percent rating. In summary, the Veteran’s right hip scar met the criteria for a rating of 10 percent, and no higher, prior to November 4, 2019. However, the Veteran’s right middle finger scar, right hip scars, and left hip scars, did not meet the criteria for higher initial ratings from November 4, 2019. To the extent that the Veteran seeks ratings for his service-connected scars, higher than those awarded in this decision or previously awarded, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to a compensable initial rating for herpes simplex The Veteran’s herpes simplex is rated under 38 C.F.R. § 4.118, Diagnostic Code 7806. Under Diagnostic Code 7806, a noncompensable evaluation is warranted where dermatitis or eczema covers less than five percent of the entire body or less than five percent of exposed areas affected, and no more than topical therapy was required during the previous 12-month period. A 10 percent evaluation is assigned when dermatitis or eczema is at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation is assigned when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum rating of 60 percent is assigned 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 drugs are required during the previous 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. During the pendency of the instant appeal, effective August 13, 2018, VA revised the criteria for rating skin disabilities, which are applicable to the Veteran’s claim from the effective date of the rulemaking, if more favorable to the Veteran. See 83 Fed. Reg. 32593 (July 13, 2018). In Johnson v. Shulkin, the Federal Circuit determined that DC 7806’s use of “systemic therapy such as corticosteroids” generally does not include application of topical corticosteroids which affect only the area to which it is applied. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). The Federal Circuit defined systemic therapy as treatment pertaining to or affecting the body as a whole, while topical therapy was defined as treatment pertaining to a particular surface area and affecting only the area to which it is applied. Id. at 1355. Thus, according to the Federal Circuit, the application of a topical corticosteroid does not automatically mean systemic therapy was used. Id. Rather, a determination as to whether use of a topical corticosteroid is considered systemic therapy or topical therapy will be based on the factual circumstances of each case. Id. at 1356. The Federal Circuit then opined that one of the factual circumstances for consideration is whether the topical corticosteroid was administered on a large enough scale to affect the body as a whole. Id. at 1355. In Burton v. Wilkie, the Court of Appeals for Veterans Claims (the Court) addressed “systemic therapy” in the context of topical treatment. The Court held that the method by which the treatment works is another factual circumstance for consideration when determining whether a topical treatment can be deemed systemic therapy. Burton v. Wilkie, 30 Vet. App. 286, 291 (2018). Additionally, the Court held that a finding of systemic therapy is not limited to the use of corticosteroids or immunosuppressive drugs. Rather, the VA must determine whether any given treatment is “like” a corticosteroid or other immunosuppressive drug in that it affects the body as a whole. Id. at 295. The Court added that determining whether a treatment is systemic therapy is a factual determination that will likely require a medical opinion for resolution. Id. In this case, the Veteran was provided a VA examination in November 2019. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The VA examiner noted that the Veteran had several skin conditions, including herpes simplex. Upon examination, the VA examiner noted that the Veteran constantly/near-constantly takes oral and topical medication related to his herpes simplex, staph infection nares, and seborrhea dermatitis. However, the VA examiner did not identify for which skin condition he takes the medication. Additionally, the VA examiner did not indicate the approximate total body area and approximate total exposed body area affected by the Veteran’s herpes simplex. 2. Entitlement to a TDIU. Concerning entitlement to a TDIU, the Board finds that any determinations with respect to the remanded claim would materially affect a determination concerning entitlement to a TDIU. As such, it is inextricably intertwined with the increased rating claim being remanded and must therefore be remanded as well. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). This matter is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to ascertain the current nature and severity of his service-connected herpes simplex. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must also determine the percentage of body coverage, as well as percentage of exposed body coverage related to the Veteran’s herpes simplex. The examiner must also ascertain whether the Veteran requires systemic therapy, such as corticosteroids or other immunosuppressive drugs for his service-connected herpes simplex. The examiner must determine with what frequency and for how long the systemic therapy has been administered over the previous twelve months. CHRISTOPHER A. WENDELL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. G. LeMoine, 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.