Citation Nr: 21016482 Decision Date: 03/22/21 Archive Date: 03/22/21 DOCKET NO. 06-17 763A DATE: March 22, 2021 ORDER Entitlement to service connection for dysthymic disorder as secondary to service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne, is granted. Entitlement to an extraschedular rating for the Veteran’s service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne, prior to September 25, 2009 is denied. Entitlement to an extraschedular rating for the Veteran’s service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne, since September 25, 2009 is denied. FINDINGS OF FACT 1. It is as likely as not that the Veteran’s current dysthymic disorder is related to his service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne. 2. Prior to September 25, 2009, the Veteran’s service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne are not so exceptional or unusual that the normal provisions of the rating schedule do not adequately compensate the Veteran for these service-connected disabilities, nor do they present an exceptional or unusual disability picture such as marked interference with employment or frequent periods of hospitalization. 3. Since September 25, 2009, the Veteran’s service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne are not so exceptional or unusual that the normal provisions of the rating schedule do not adequately compensate the Veteran for these service-connected disabilities, nor do they present an exceptional or unusual disability picture such as marked interference with employment or frequent periods of hospitalization. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran’s favor, the criteria for an award of service connection for dysthymic disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for an extraschedular rating for skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne have not been met prior to September 25, 2009. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.321(b)(1). 3. The criteria for an extraschedular rating for skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne have not been met since September 25, 2009. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.321(b)(1). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1975 to December 1978. Procedural Background The case has an extensive procedural history, as follows: This case initially came before the Board of Veterans’ Appeals (Board) on appeal of an August 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The August 2006 rating decision continued the 10 percent disability rating assigned to the Veteran’s folliculitis. In July 2009, the Board reopened the claim for service connection for discoid lupus and denied the claim on the merits. The Board also remanded the claim for an increased rating for folliculitis. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). In April 2010, the Court remanded the appeal for the claim for service connection for discoid lupus for development consistent with the April 2010 joint motion for remand. Thereafter, in an August 2011 rating decision, the RO granted service connection for discoid lupus and assigned a 10 percent disability rating, effective November 4, 2004. In October 2011, the Board denied a disability rating in excess 10 percent for folliculitis prior to September 25, 2009 and granted a 30 percent disability rating for folliculitis thereafter. The Veteran appealed the Board’s denial of a higher rating for folliculitis to the Veterans Court. In March 2013, the Veterans Court granted the joint motion for partial remand, vacating the Board’s decision as to a disability rating in excess of 10 percent for folliculitis, prior to September 25, 2009, and a disability rating in excess of 30 percent for folliculitis thereafter, to include on an extraschedular basis, and remanding those matters to the Board for development. In June 2013, the Board remanded the claim for additional development. In November 2013, the Board again denied the Veteran’s claim for a rating in excess of 10 percent each for discoid lupus and folliculitis, prior to September 25, 2009, and in excess of a combined 30 percent disability rating thereafter, and denied referral for extraschedular consideration for both periods. In April 2015, the Court vacated and remanded the November 2013 Board decision for additional development. In September 2015, the Board remanded the case for additional consideration by the Director of Compensation Service to determine whether an extraschedular disability rating was warranted under 38 C.F.R. § 3.321 (b). In November 2015, the Director of Compensation and Pension determined that extraschedular consideration was not warranted and its reasoning stated that the Veteran’s skin disability was not so unusual or exceptional as to render the use of the regular schedular standard impractical. In an August 2017 decision, the Board denied the Veteran’s claim of entitlement, to an extraschedular basis, for his service-connected skin disabilities. In doing so, the Board concluded that the Veteran’s reported symptoms such as scaling, discoloration, decreased pigmentation, increased pigmentation, rashes, peeling skin, itching, and dryness were contemplated by the rating schedule. It also acknowledged the Veteran’s complaints that he was unable to remain outside for prolonged periods as sunlight aggravated his skin disability, his condition required him to withdraw from social and family activities and work the night shift to limit exposure to the sun. Although the Board noted that the referenced symptoms were not explicitly listed in the applicable diagnostic codes, it stated that “[t]he question is not whether the Veteran’s particular symptoms are explicitly listed in the diagnostic code but whether the symptoms and level of his disability are adequately contemplated by the schedular rating system.” See Thun v. Peake, 22 Vet. App. at 115. Id. Thereafter, the Board concluded that the Veteran’s symptoms were adequately contemplated by the schedular system, and the assigned ratings were adequate. In September 2018, the Veteran filed an appeal with the Court contesting the Board’s August 2017 decision to the extent that it failed to provide adequate reasons and bases for denying his claim and failed to adequately consider positive evidence of record. In October 2018, the Court vacated and remanded the Board’s August 2017 decision pursuant to a Joint Motion for Partial Remand submitted by the parties. As a preliminary matter, the Board notes that the August 2017 decision provided favorable findings, to include assigning an evaluation of 30 percent rating for folliculitis of the facial area, facial scars, and acne prior to September 25, 2009; and a 60 percent rating for folliculitis of the facial area, facial scars, and acne from October 13, 2011.The Court decision does not disturb those findings and the Board further notes that the Veteran does not wish to pursue any additional increase to the assigned ratings. Therefore, the issues were considered abandoned and dismissed. Additionally, the Veteran expressed a desire to abandon his appeal of the Board’s denial of his increased rating claims for an evaluation in excess of 10 percent for discoid lupus erythematosus, prior to September 25, 2009, and an evaluation in excess of 30 percent for discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne from September 25, 2009 to October 12, 2011. Accordingly, these issues were also considered dismissed. In a February 2019 Board decision, the matter of an extraschedular rating for the Veteran’s service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne, was remanded for further development so that the Board could obtain additional information necessary to comply with the CAVC remand. Specifically, the RO was ordered to schedule the Veteran for an addendum opinion by an appropriate clinician to determine the current severity of his service-connected skin disabilities, to include consideration of whether an extra schedular rating was warranted. Additionally, the examiner was requested to provide a medical opinion that reflects consideration of all of the facts in evidence and to comment on the Veteran’s complaints that his symptoms significantly impact his ability to work and engage in normal activities of daily living. It was specifically requested that the examiner consider the Veteran’s assertion that he suffers from depression and impaired social functioning due to the current severity of his skin condition, to include as due to “people staring” when he is in public and at social and family gatherings, or in the workplace. The Board finds that the AOJ has substantially complied with the prior remand directives, to the extent possible. See Stegall v. West, 11 Vet. App. 268 1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). See also D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) and Dyment v. West, 13 Vet. App. 141, 146-47 (1999) aff’d, Dyment v. Principi, 287 F.3d 1377 (2002) (holding that further remand not necessary under Stegall where the Board’s remand instructions were substantially complied with). In summary, the duties imposed by the VCAA have been considered and satisfied. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim herein decided. Therefore, there is no prejudice to the Veteran in the Board proceeding to a decision on these matters, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Accordingly, the Board finds that the Remand directives were substantially complied with and, thus, there is no Stegall violation in this case. The file has been returned to the Board and the matter is now properly before the Board for adjudication. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Continuity of symptomatology may also provide a basis for a grant of service connection for those diseases defined as “chronic” by VA. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for any disease initially 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, any reasonable doubt is resolved in favor of the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a 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). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Entitlement to service connection for dysthymic disorder as secondary to service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne. The Board initially notes that in the October 2018 Joint Motion for Partial Remand, the Veteran argued that his skin disabilities also “cause [his] feelings and emotions to become in a depression state of mind when [he is]out in the public, at a social function, with family, or at work because people stare at [him] for not having normal skin condition.” See April 2, 2013 Letter from Appellant to VA. The Court ordered that upon remand, the Board should address this argument and provide an adequate statement of reasons or bases for its determination. As the Court recently noted, the Board is required to develop and adjudicate related secondary service connection for disabilities that are reasonably raised during the adjudication of a formally initiated claim for an increased rating for the primary service-connected disability. Bailey v. Wilkie, No. 19-2661, 2021 WL 45679 (Jan. 6, 2021). To that end, the Board will consider the symptoms of this disability as part of a separate service connection evaluation that stems from the Veteran’s increased rating appeal, including on a extraschedular basis, for his skin disabilities. The Veteran asserts that his skin disabilities have caused him to become depressed. See April 2, 2013 Letter from Appellant to VA. The Veteran’s treatment records demonstrate that he has a diagnosis of discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne for which he is service-connected. A January 1980 examination stated that the Veteran had skin lesions with redness on his face. A March 1982 VA examination includes a description of the Veteran’s skin condition. It was noted that the Veteran reported that his face breaks out so much at times that it causes him anxiety and sometimes he cannot function properly on a daily basis because of this. In an April 1984 examination the Veteran reported that his face breaks out with large small painful cysts surrounded with inflammation and red bumps and further reported that none of the cream is helping and that his facial appearance has caused and is causing deep psychological embarrassment, anxiety, nervousness, worry, shyness, discomfort and withdrawal from social life. In a November 2010 VA examination it was noted that the onset of the Veteran’s discoid lupus erythrmatosus skin condition which began in in 1977 when he was stationed in Germany resulted in his face being covered with red patches on his forehead, cheeks, and nose. The examiner opined that it was at least as likely as not that the Veteran’s current skin condition was at least as likely as not incurred in service given the histologic pathology and diagnosis in 1977 and initiation of treatment. A VA examination dated November 2019 was provided by Dr. J.F. who stated that the Veteran reported restricted social activity, and absence of friendships, social activities, anxiety, depression and low self-worth, when he perceives others staring at him, due to his skin condition. Specifically, the Veteran reported symptoms of depressed mood, anergia, anhedonia, social isolation, difficulty falling and staying asleep, insomnia, low self esteem and feelings of hopelessness/helplessness as being secondary to his service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne. The Board finds that given the visibility of the Veteran’s skin condition and its pervasive nature, when resolving all reasonable doubt in favor of the Veteran, it is as likely as not that the Veteran’s skin condition resulted in emotional trauma to include depression, anxiety, and dysthymic disorder. The Board finds the Veteran’s statements linking his feelings of depression to his skin condition to be credible and supported by the evidence of record. The treatment records unambiguously demonstrate the effects of the Veteran’s skin condition and the Board finds that as a lay person the Veteran can directly characterize the feelings and emotions that he personally experienced and felt as a result of his skin condition. The Veteran’s statements regarding the impact of his skin condition on his emotional and mental health and his social interactions are consistent and are not contradicted by other lay or medical evidence of record. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.159; see Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The lay observations and symptoms that were reported were all consistent with the clinical evidence or record and the findings of the medical examiners and as such, these statements are probative. Moreover, the Board observes that the Veteran’s statements made during medical treatment are plausible and credible. The Board puts significant emphasis and probative weight on the March 1982 VA examination where the Veteran reported that his face breaks out so much at times that it causes him anxiety and sometimes he cannot function properly on a daily basis because of this. The Board also places significant emphasis and probative weight on the April 1984 examination where the Veteran stated that his face breaks out with large small painful cysts surrounded with inflammation and red bumps and further noted that none of the cream is helping and that his facial appearance has caused and is causing deep psychological embarrassment, anxiety, nervousness, worry, shyness, discomfort and withdrawal from social life. Additionally, the Board assigns significant probative weight to the VA examination dated November 2019 that was provided by Dr. J.F. who stated that the Veteran reported restricted social activity, and absence of friendships, social activities, anxiety, depression and low self-worth, when he perceives others staring at him, due to his skin condition. The Board finds persuasive that during the November 2019 examination, the Veteran reported symptoms of depressed mood, anergia, anhedonia, social isolation, difficulty falling and staying asleep, insomnia, low self esteem and feelings of hopelessness/helplessness as being secondary to his service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne. To the extent that the Veteran directly experienced his own symptoms he is competent to provide this information. Further, when assessing the credibility of such statements, the factors which must be considered include facial plausibility; internal consistency; consistency with other evidence; self-interest or bias; lay statements made during treatment; and personal knowledge or experience. See Caluza v. Brown, 7 Vet. App. 498 (1995). The Board finds that there is sufficient evidence to corroborate that the Veteran’s dysthymic disorder is caused by his service-connected skin disabilities. Upon consideration of the evidence of record, the Board finds that, resolving reasonable doubt in the Veteran’s favor, service connection for dysthymic disorder as secondary to the Veteran’s service-connected skin disabilities, is hereby granted. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an extraschedular rating for the Veteran’s service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne prior to September 25, 2009. 3. Entitlement to an extraschedular rating for the Veteran’s service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne, since September 25, 2009. The Veteran’s skin disability is rated pursuant to Diagnostic Code 7809-7806. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2016). Prior to September 25, 2009, the Veteran’s folliculitis and discoid lupus were rated separately at 10 percent each. The Veteran’s folliculitis was rated pursuant to Diagnostic Code 7817-7828 and his discoid lupus was rated pursuant to Diagnostic Code 7809-7806. Effective, September 25, 2009, the two skin disorders were combined and a single disability rating was assigned for his entire skin disability involving the head, face, and neck. Accordingly, the Board will consider whether increased ratings are warranted under the respective applicable diagnostic codes for both periods on appeal. The Board notes that the criteria pertaining to rating skin disabilities were revised, effective October 23, 2008. The revisions did not change the Diagnostic Codes involved in rating the Veteran’s skin disabilities under Diagnostic Codes7800,7806, 7817, and 7828. Even so, those revised provisions are applicable only to claims received on or after October 23, 2008, unless the claimant requests review under the revised criteria. 73 Fed. Reg. 54708 (Sept. 23. 2008). Because the current claim was received prior to that date and the Veteran has not requested to be rated under the revised criteria, the revisions do not apply in this case. Skin disabilities rated under Diagnostic Code 7809 are assigned a rating based on the predominant disability under Diagnostic Code 7800, relating to disfigurement of head, face, or neck; Diagnostic Code 7806, relating to dermatitis; or Diagnostic Codes 7801 through 7805, relating to scars. See 38 C.F.R. § 4.118, Diagnostic Code 7809 (2016). In this case, Diagnostic Code 7806 is most applicable. Under Diagnostic Code 7817, a 10 percent rating is warranted for exfoliative dermatitis with any extent of involvement of the skin, and; systemic therapy such as therapeutic doses of corticosteroids, immunosuppressive retinoids, PUVA (psoralen with long-wave ultraviolet-A light) or UVB (ultraviolet-B light) treatments, or electron beam therapy required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating for any extent of involvement of the skin, and; systemic therapy such as therapeutic doses of corticosteroids, immunosuppressive retinoids, PUVA (psoralen with long-wave ultraviolet-A light) or UVB (ultraviolet-B light) treatments, or electron beam therapy required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating for generalized involvement of the skin without systemic manifestations, and; constant or near-constant systemic therapy such as therapeutic doses of corticosteroids, immunosuppressive retinoids, PUVA (psoralen with long-wave ultraviolet-A light) or UVB (ultraviolet-B light) treatments, or electron beam therapy required during the past 12-month period. A maximum 100 percent schedular rating for generalized involvement of the skin, plus systemic manifestations (such as fever, weight loss, and hypoproteinemia), and; constant or near-constant systemic therapy such as therapeutic doses of corticosteroids, immunosuppressive retinoids, PUVA (psoralen with long-wave ultraviolet-A light) or UVB (ultraviolet-B light) treatments, or electron beam therapy required during the past 12-month period. 38C.F.R. §4.118, Diagnostic Code 7817. Under Diagnostic Code 7828, a 10 percent schedular rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or; deep acne other than on the face and neck. A maximum 30 percent schedular rating is assigned for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. 38C.F.R. §4.118, Diagnostic Code 7828. Under Diagnostic Code 7806, a noncompensable rating is warranted for conditions with less than five percent of the entire body or less than five percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating for conditions affecting at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or where there has been a requirement of 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 rating is warranted for conditions affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or if there has been a requirement of 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 schedular rating is assigned if the condition affects more than 40 percent of the entire body or more than 40 percent of exposed areas; or where constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. In Johnson v. McDonald, the Veterans Court found that the language of Diagnostic Code 7806 provides that the phrase “systemic therapy such as corticosteroids” unambiguously included topical corticosteroids. In July 2017, the Federal Circuit issued an opinion that reversed the Veterans Court holding in Johnson v. McDonald. See Johnson v. Shulkin, 2017 U.S. App. LEXIS 12601, 2017 WL 2989492. The Federal Circuit held that Diagnostic Code 7806 does not automatically mean that all corticosteroids and other immunosuppressive drugs, regardless of how localized the treatment, is considered systemic therapy. Under Diagnostic Codes 7806 and 7817, a skin disability can be rated under Diagnostic Code 7800 for disfigurement of the head, face, or neck, or as scars under Diagnostic Codes 7801, 7802, 7803, 7804, or 7805, depending on the predominant disability. Under Diagnostic Code 7800, a 10 percent rating is warranted for scar(s) of the head, face, or neck, or other disfigurement of the head, face, or neck, with one characteristic of disfigurement. A 20 percent rating is warranted for scar(s) of the head, face, or neck, or other disfigurement of the head, face, or neck, with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with two or three characteristics of disfigurement. A 50 percent rating is warranted for scar(s) of the head, face, or neck, or other disfigurement of the head, face, or neck, with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with four or five characteristics of disfigurement. An 80 percent rating is warranted for scar(s) of the head, face, or neck, or other disfigurement of the head, face, or neck, with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with six or more characteristics of disfigurement. Note 1 provides that the 8 characteristics of disfigurement are: scar 5 or more inches (13 or more centimeters (cm)) in length; scar at least one-quarter inch (0.6 cm) wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo-or hyper-pigmented in an area exceeding 6 square inches (39 squared cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Prior to the October 2008 amendments, Diagnostic Code 7803 provided that a 10 percent rating is warranted for scars that are superficial and unstable and Diagnostic Code 7804 provided that a 10 percent rating is warranted for scars which are superficial and painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7803-7804 (2008). As already stated, pursuant to the October 2018 Court Joint Motion for Partial Remand, the Board will not disturb the assigned schedular ratings for the Veteran’s skin disabilities and will instead address whether an extraschedular rating is warranted during the periods on appeal. Extraschedular Rating: Legal Criteria Pursuant to 38 C.F.R. § 3.321 (b)(1), the Director of Compensation and Pension, is authorized to approve an extra-scheduler evaluation if the case “presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular scheduler standards.” 38 C.F.R. § 3.321 (b)(1). There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008); aff'd Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). First, there must be a comparison between the level of severity and symptomatology of the claimant’s service-connected disability and the established criteria found in the rating schedule for that disability to determine whether the disability picture is adequately contemplated by the rating schedule. Id. In the second step of the inquiry, if the schedular evaluation does not contemplate the claimant’s level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant’s exceptional disability picture exhibits other related factors such as those provided by the regulation as “governing norms.” Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the rating schedule is inadequate to evaluate the claimant’s disability picture and that picture has related factors such as “marked interference with employment” and “frequent periods of hospitalization,” then the third step is to refer the case to the Under Secretary for Benefits or the Director of C&P Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-scheduler rating. Id. In other words, the Board may not address the issue in the first instance. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Factual Background The Veteran contends that he is entitled an extraschedular rating for his service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne. In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2016) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disability. Private treatment records from the Veteran’s dermatologist, Dr. R.R., showed treatment for his skin disability from March 2002 to June 2004. He was treated with topical solution and sunscreen. An August 2004 letter from Dr. R.R. included diagnoses of discoid lupus erythematosus, cystic acne, and folliculitis. Dr. R.R. described periodic exacerbations and remissions of his lupus erythematosus since he started treating the Veteran. His discoid lupus responded to topical steroid treatment, sun avoidance, sun screening, and protective clothing. His folliculitis and acne lesion symptoms were treated with two percent erythromycin and oral antibiotics. In August 2004, the Veteran was prescribed 14 Adoxa (doxycycline) tablets taken orally, with two additional refills remaining before August 2005. In September 2004, the Veteran stated that he saw a dermatologist every four to eight weeks or sooner if he had a flare-up. He also reported that he had to limit activities with his children because the sun aggravated his skin disability. The Veteran was provided a VA examination in May 2005. The examiner provided a diagnosis of discoid lupus erythematosus. The Veteran had skin lesions on his face and neck, which were characterized by discoloration, decreased pigmentation, increased pigmentation, and scaling. The examiner described dark discoloration on the left ear lobe the size of a dime. He had multiple patchy rashes on his neck, forehead, nose, left malar area, and right lower face. The rashes were scaly, reddened, and ranged in size from a nickel to a dime. His skin disability affected less than five present of the exposed areas and less than five percent of the total body area. The Veteran described intermittent itching, peeling skin, pigment change, rash, and pain. His skin disability was intermittent with remissions and was treated with steroid cream and oral/injected steroids, both used less than six weeks within the previous 12 months. The examiner found that his skin disability did not significantly impact his occupation, but moderately impacted chores, shopping, recreation, and traveling. His skin disorder also prevented sports and limited activities involving exposure to the sun. Private treatment records from Dr. R.R. from January 2005 to February 2006 documented flare-ups of his discoid lupus and continued use of topical creams. An April 2006 Department of Labor form completed by Dr. R.R. indicated that the Veteran’s skin disability was a serious health condition. The Veteran needed to take time off work to attend medical appointments five to six times a year. The Veteran experienced flare-ups of his discoid lupus four to five times a year. His treatment regimen included topical cream, topical steroids, and oral antibiotics. Dr. R.R. suggested that the Veteran was unable to perform one or more of the essential functions of his job and that he had to use sunscreen, wear protective clothing, and avoid prolonged exposure to the sun. In February 2006, the Veteran received 14 Doryx (doxycycline) tablets to be taken orally once per day with an additional four refills remaining before February 2007. The prescription for 14 Doryx tablets was refilled in April 2006. Later in April 2006, the Veteran received an additional 28 Doryx tablets. In April 2006, the Veteran requested specialized treatment from a dermatologist for scheduled and unscheduled office visits for flare-ups, possible incision and drainage of cysts, skin lesions, facial scars, acne folliculitis, discoid lupus, and infections in the facial area. He explained that his regimen included topical and oral antibiotics, topical steroids, sunscreen lotion, and blood work. In April 2006, the Veteran stated that he currently or previously used various drugs to treat his skin disability, to include oral antibiotics, locoid lipo cream, bactroban cream, cloderm cream, zoderm benzoyl peroxide cleanser, dermatop cream, cutivatecream, pandel cream, cleocin-Ttopical solution, duac topical solution, clindagel topical gel, duace sodium sulfacetamide, topicort cream, ucort acetate cream, lidex-E cream, klaron, and apexicon cream. In May 2006 the Veteran presented with an inflamed superficial hemangioma. Three level recuts were completed. Private treatment records continued to show folliculitis legions on his face and use of topical treatments. In a June 2006 statement, the Veteran’s spouse provided additional details regarding his skin disability. The Veteran had several scars from previous lesions and continued to develop new lesions. His skin disability restricted outdoor activities with his children and travel. In June 2006, the Veteran continued to report ongoing treatment for his skin disability, which included incision and drainage of cystic lesions. His skin disability was manifested by painful red cysts, pustules, constant itching, extensive lesions, marked disfigurement, and constant scaling. He expressed feelings of embarrassment due to his skin problems. The Veteran missed time from work for scheduled and unscheduled medical appointments. His skin disability was aggravated by the sun during his one to two-hour commute to work. The Veteran also stated that his activities were limited and that he was unable to complete outdoor chores. He experienced more flare-ups than documented in his medical records because he limited his medical appointments due to rising out-of-pocket expenses. He reported that in the past he used steroid creams and injected steroids. He also reported regular use of clindamycin solution, which he stated caused dry skin, burning, stinging, and redness. He stated that the various antibiotics caused nausea, diarrhea, and dry mouth. In a July 2006 letter, Dr. R.R. explained that the Veteran had a history of folliculitis with recurrent episodes of cysts, pustules, and papules on the face area. His skin disability was manifested by recurrent exacerbations and remissions of his folliculitis and discoid lupus erythematosus lesions. His folliculitis was treated with topical clindamycin solution, oral antibiotics, incisions, and drainage. His discoid lupus erythematosus lesions were treated with topical steroids. He was advised to wear sun-protective clothing and sunscreens to prevent a recurrence of his discoid lupus flares. The Veteran was afforded a VA scars examination in July 2006. The examiner noted that his acneiform folliculitis was well controlled with current management. A physical examination revealed multiple small facial scars from healed acneiform folliculitis. There were no current symptoms related to scars from facial acne. Specifically, the examination was negative for pain; adherence to underlying tissue; elevation or depression of the scars on palpation; inflammation; edema; keloid formation; color distortion; asymmetry; disfigurement; induration or inflexibility of skin in the area of the scars; limitation of motion; or limitation of function. The texture was normal and the scars appeared stable and superficial. The diagnosis was multiple well-healed and non-symptomatic scars from acneiform folliculitis. September 2006 VA treatment records showed that the Veteran was prescribed cleocin topical, cloderm cream, apexicon cream, and locoid lipocream. His VA problems list included acne dermatitis and chronic folliculitis. In his July 2007 substantive appeal, the Veteran asserted that the May 2005 and July 2006 VA examinations did not accurately reflect the severity of his skin disability because both exams were conducted during periods of remission. In October 2007, the Veteran received 14 Doryx tablets to be taken orally, with two refills remaining before October 2008. A November 2007 pharmacy receipt showed that the Veteran was given 14 Doryx tablets to be taken orally, with one additional refill remaining. In December 2007, the Veteran reported an increase in flare-ups, unscheduled appointments, and injections. He was taking antibiotics and using creams, ointments, and topical solutions. In May 2008, the Veteran was prescribed 14 Doryx tablets, taken orally. A September 2008 pharmacy receipt indicated that the Veteran was prescribed 13 Doryx tablets, with an additional two refills allowed before September 2009. In an October 2008 letter, Dr. R.R. continued to report recurrent exacerbations and remissions of his folliculitis and periodic exacerbations of his discoid lupus. His folliculitis continued to be treated with topical antibiotic solutions, oral antibiotics, and incision and drainage. His discoid lupus was treated with topical steroids during a flare-up. Dr. R.R. continued to advise the Veteran to limit his exposure to the sun because sunlight aggravated his discoid lupus. The Veteran also submitted pharmacy receipts for cleocin, doryx, and azelex cream between February 2008 and December 2008. In December 2008, the Veteran received a total of 19 Doryx tablets. In May 2009, the Veteran indicated that he experienced more frequent flare-ups. He stated that from December 2007 to April 2009, he had a total of 18 visits. Since November 2007, the Veteran used desonate gel, topicort, azelex cream,and aquaphor healing. He also reported stretch marks and a high level of protein in his urine caused by his skin disability or the medication used to treat it. He explained that his lesions were lasting longer and increasing in severity. The Veteran was unable to coach his son’s baseball team and complete outdoor chores because of the sun and heat. He reported withdrawing from his family or getting upset with them because of the way his face looked. His skin disability affected his self-confidence and he limited his time in the public. The Veteran underwent a VA examination in September 2009. The examiner found small, shallow, and nontender scars scattered on each cheek. The largest scar was located on the lateral aspect of the right cheek, elongated, and ¾ by ¼ centimeter. The Veteran reported pain and skin breakdown over the scars two or more times per year, but less than monthly. A physical examination revealed scars less than six square inches on each cheek, with the largest scar measuring ¼ by ¾ centimeter. The scars were painful; had no signs of skin breakdown; were superficial; had no inflammation, edema, or keloid formation; had no abnormal texture; had no underlying soft tissue loss; had no induration or inflexibility; had elevated or depressed contour; were not adherent to underlying tissue; and had no other disabling effects. The skin area with abnormal pigmentation was ¼ centimeter long and 1/8 centimeter wide with red discoloration. The scars did not show gross distortion or asymmetry. His folliculitis symptoms included itching, tenderness, swelling and pustular formation. During the physical examination he was observed to have lesions under the left chin and the corners of the mustache. The Veteran described itchy and burning lesions. The diagnosis was acneform folliculitis and pseudo-folliculitis scars of the cheeks bilaterally. The Veteran’s acute lesions were drained with a needle or injected with cortisone to reduce swelling and inflammation. He was prescribed antibiotics and used various skin creams, such as topical cortisone. He used doxycycline once or twice daily, two times per month. The examiner noted that the doxycycline was a systemic treatment and that the Veteran used the medication one to six weeks within the past year. The Veteran reported that the side effects included horizontal stretch marks on the upper chest and buttocks. He reported that he missed less than one week of work in the past year due to his skin disability. The examiner found that his skin disability had significant effects on his employment as a result of pain, itching, and burning. He also worked the night shift to avoid sunlight. His symptoms also impacted his ability to drive, groom, and socialize. Less than five percent of the exposed areas were affected and less than five percent of the total body area was affected. January 2010 private treatment records showed that the Veteran continued to use cleaning solution and was not using topical steroids. There were no new lesions. In March 2010, the Veteran had no ingrown hairs, pustules, or cysts. He was instructed to continue with the topical cream. He was prescribed clindamycin solution in April 2010 and October 2010. In July 2010, the Veteran had a few ingrown hairs. In November 2010, he presented with a cyst on his left cheek and a rash caused by ingrown hairs. The Veteran was provided a VA examination in November 2010. The examiner noted that the Veteran continued to have problems with discoid lupus. His symptoms included erythematous patches on the forehead, nose, and external ear. Physical examination reflected dry erythematous patches to the forehead, which were barely visible because they were not inflamed. Treatment consisted of a topical corticosteroid, which he used as needed and for longer than six weeks in the past year. The examiner found no side effects of treatment. His discoid lupus affected less than five percent of the exposed areas and less than five percent of the total body area. April 2011 private treatment records showed that the Veteran was using topical clindamycin solution. The Veteran denied pain and burning. He complained of a rash on the right mandible. In June 2011, the Veteran presented with a few ingrown hairs in the beard area. Examination did not reflect any cysts or pustules. He was instructed to continue the topical cream and was prescribed cutivate lotion. He continued to use the cutivate lotion in July 2011 and September 2011. In August 2011, the Veteran presented with a flare on his nose. There were a few comedones and papules. He was instructed to continue the topical steroid. In October 2011, the Veteran experienced a flare-up for at least one week; he was prescribed altabax, Doryx, and cleocin-Tsolution. In October 2011, the Veteran was prescribed 30 Doryx tables to take by mouth once a day and another two refills were available thereafter. A November 2011 private treatment record noted that the Veteran had a flare-up the previous week; he was prescribed 30 Morgidox (doxycycline) tablets to be taken daily for 30 days. Pharmacy receipts indicated that he was prescribed clindamycin phosphate in November 2011, January 2012, March 2012, and May 2012. In January 2012, the Veteran received another 30 day supply of doxycycline; this was the last of 2 refills. In March 2012, the Veteran was given 30 doxycycline tablets and an additional refill was available if requested before November 2012. In May 2012, the Veteran stated that his discoid lupus met the criteria for a 30 percent rating based on his used of corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more. In August 2012, the Veteran received a 30-day supply of doxycycline. In October 2012, the Veteran explained that his acne and folliculitis symptoms were cysts, ingrown hair, facial swelling, pain, and itching. His discoid lupus symptoms were red/dark patches, peeling skin, and sores. He stated that he only used corticosteroids to treat discoid lupus. He submitted an October 2012 prescription for a 30-day supply of Doryx with four refills remaining. In a statement received in October 2012, the Veteran stated that he had a flare-up the first week of October 2011. Dr. R.R. injected the problem areas and prescribed several medications. A couple of weeks later, the Veteran experienced a more widespread flare-up. He contacted Dr. R.R. and was instructed to discontinue the cleocin-T solution, but to continue the other prescribed medications. Thereafter, he injected the areas that flared up and advised the Veteran to continue the Doryx pills, use the cleocin-Tonce a day, stop altabax, and start using azelaic. He was given a prescription for Morgidox if needed. In April 2013, the Veteran expressed feelings of depression as a result of his skin disability. He reported that he felt depressed when going out in public, at social functions, around family, and at work. The Veteran’s private dermatologist prescribed various medications to treat his symptoms, however, the medicine sometimes worsened his flare-ups. The clindamycin topical solution caused burning, itching, dryness, peeling, and redness. The antibiotics caused stomach irritation, nausea, itching, dry mouth, and sun sensitivity. In June 2013, he was prescribed another antibiotic, namely minocycline. Treatment records indicated that he was prescribed 60 tablets with 11 refills remaining. July 2013 private treatment records showed a few ingrown hairs on his neck and a small cyst on the right chin. In August 2013 he presented with two small cysts. He was prescribed doxycycline. The Veteran was afforded a VA examination in August 2013. The examiner provided diagnoses of folliculitis of the facial area with facial scarring and acne and discoid lupus erythematosus. The examiner noted that the facial scarring caused by his discoid lupus was minimal and there was no evidence of disfigurement. It was difficult to visualize the scarring in the beard area due to facial hair. The skin in the area of the scars was hyperpigmented and measured 11 centimeters by 7 centimeters. The total area of the hyperpigmented area measured 77 centimeters squared. The Veteran had a lesion in the auricle of the left ear that measured approximately .5 centimeter by .5 centimeter. Length and width at the widest part of the scar was one centimeter by one centimeter. Physical examination revealed that there was no elevation, depression, or adherence to underlying tissue; missing underlying tissue; induration or inflexibility; abnormal texture; gross distortion or asymmetry of facial features or visible or palpable tissue loss; limitation of function; or any other pertinent physical findings. The examiner concluded that the Veteran’s scars did not impact his ability to work. The examiner also conducted a separate skin examination. At the time of the examination the Veteran’s discoid lupus was manifested by two skin lesions. There was a mild erythematous lesion on the right side of his forehead and a constant lesion inside the left auricle of his left ear. The Veteran treated his discoid lupus lesions two to three times a week. His lesions flared-up regularly when he was exposed to the sun. His folliculitis was treated daily with clindamycin solution to his face. He reported flare-ups every two to three months. If the antibiotics were ineffective, he received steroid injections into the lesions. The Veteran stated that he was told that he developed stretch marks secondary to chronic topical steroid use. The examiner noted that the Veteran was treated with minocycline, an oral medication, for six weeks, but not constantly. He used minocycline to treat folliculitis flare-ups and clindamycin solution daily to manage folliculitis. He used apexicon for flare-ups of discoid lupus. The examiner also found that the Veteran was treated with topical corticosteroids greater than six weeks, but not constantly. His skin disability affected less than five percent of the exposed areas and less than five percent of the total body area. The examiner concluded based on the Veteran’s current appearance, there was no evidence of severe disfigurement. His folliculitis and discoid lupus lesions were stable and there was no evidence of facial scarring from acne. His skin disability did not impact his ability to work and there were no known limitations in his work hours due to his skin disability. His discoid lupus was aggravated by the sun, therefore, the Veteran had to avoid direct sunlight exposure during the hottest part of the day and protect his skin. He was able to perform yardwork with restrictions. He was prescribed doxycycline in September 2013 and had one more refill remaining. In October 2013, the Veteran reported a flare-up of his discoid lupus and acne. He was prescribed cleocin T solution and locoid lotion. The Veteran also submitted an October 2013 pharmacy receipt for 30tablets of doxycycline to be taken daily, and six additional refills remaining. In October 2013, the Veteran was given a 90 day supply of doxycycline, with three remaining refills. He was given another 30 day supply in December 2013. In January 2014, the Veteran was given 30 minocycline tablets and was authorized for nine additional refills. The Veteran obtained a refill in May 2014, June 2014, July 2014, and September 2014. An April 2015 treatment record showed that the Veteran was given a 30 day supply of minocycline. This was the fourth refill out of twelve. He continued to refill the prescription in May 2015 and June 2015. The Veteran underwent a VA examination in June 2015. The examiner found that the Veteran had three scars located on his nose, right cheek, and the left auricle of the left ear. The scars were not painful or unstable. The scar on his nose measured 0.5 centimeter by 0.3 centimeter and was hyperpigmented. The scar on his right cheek measured 0.5 centimeter by 0.2 centimeter and the surface contour was elevated on palpation. The scar on the left ear measured 0.5 centimeter by 0.6 centimeter and the surface contour was elevated on palpation. The total area of the skin with hyperpigmentation was .45 centimeter squared. The total area of the skin with missing underlying soft tissue was 0.55 centimeter squared. There was no gross distortion or asymmetry of facial features or visible or palpable tissue loss; limitation of function; or any other pertinent physical findings. His scars did not impact his ability to work. The examiner diagnosed pseudofolliculitis barbae, discoid lupus erythematosus, acne, and pseudofolliculitis. His discoid lupus caused recurrent lesions on the right forehead and nose. The nose scar was slightly hyperpigmented and irregularly shaped. The scars on the right cheek were from prior biopsies and looked like small indentations in the skin. The hyperpigmented lesion on the auricle of the left ear was constant in nature. In the last year, the Veteran constantly treated his discoid lupus with topical steroids, to include topicort, fluocinolone acetonide, and locoid cream. He was prescribed clindamycinphosphate gel greater than six weeks, but not constantly. The examiner found that the Veteran did not use systemic corticosteroids or other immunosuppressive medications in the past year. He constantly or near constantly used minocycline to treat his acne. The examiner found that his skin disability affected less than five percent of his total body area and less than five percent of the exposed area. His acne affected less than 40 percent of his face and neck. The examiner concluded that his skin disability did not impact his ability to work. The Veteran continued to treat his symptoms with minocycline in October 2015, January 2016, and March 2016. He was prescribed doxycycline in June 2016 and had three refills remaining. A July 2016 VA treatment record indicated that the Veteran was tolerating doxycycline and was taking the medication daily, with no active inflammation of acne or discoid lupus noted. In December 2018, VA treatment records indicate that Veteran had one exacerbation of his discoid lupus that resolved with some sample topical cream from Dr. R.R. and the Veteran voiced no acute presenting symptoms. Another December 2018 nursing note reported generalized aches due to the Veteran’s lupus. The Veteran submitted documents including a prescription for fluocinoloue Cream dated September 2020. The Veteran also submitted a report from Dr. R.R. dated September 2020 which describes the areas of his body that are affected by his service-connected skin conditions. Additionally, the record includes an image of Cloderm cream which the Veteran indicated he was given by his doctor in September 2020 to apply to a rash on his nose. See Medical Treatment Records Received by the Board in September 2020. The Veteran underwent another VA examination in November 2019 with Dr. M.F. The examiner noted on the Skin Diseases Disability Benefits Questionnaire (DBQ) that the Veteran has acne, discoid lupus or subacute cutaneous lupus erythematosus and folliculitis of the facial area. Additionally, it was noted that the Veteran is treated constantly with oral and topical medication. Furthermore, the examiner noted that discoid lupus erythematosus was present in less than 5 percent of the Veteran’s total body area and less than 5 percent accounted for an area that was exposed. Superficial acne was an additional skin condition noted by the examiner. With respect to pertinent physical findings, the examiner stated that the Veteran has pseudofolliculitis barbae and noted that the Veteran had a beard at the time and the examiner was unable to determine if the Veteran had razor bumps. The examiner also noted that the Veteran did not have lesions at the time of the examination. The examiner also stated that the Veteran’s skin condition impacted his ability to work and quoted the Veteran by stating that “working the night shift to avoid sunlight to help with problems, pain from acne cysts and folliculitis, ingrown hair cysts/bumps beard area, face burns and itches, swelling pustula formation develops in hair follicles.” Additionally, it is noted that the Veteran has to put on a hot wet towel with pressure to make the swelling go down and to deal with the pain of cysts at times while at work. In a medical opinion dated November 2019, the examiner Dr. M.F. stated that after thorough review of the records and in-person medical exam, he opined, that the Veteran has multiple conflicting statements of symptoms and diagnosis. Additionally, the examiner stated that many citations in the medical record state NO laboratory findings of an autoimmune disorder (such as “Lupus”) exists, as such lab findings of negative LE prep and ANA confirm (sic). Moreover, the examiner stated that upon examination, the Veteran appeared with minimal lesions apparent as noted. As far as the Veteran’s subjective complaints are concerned, the examiner stated that it appears he is well versed in his “research”, but not consistent with his objective findings. Furthermore, the examiner stated that with respect to whether the Veteran’s complaints of symptoms “significantly” impact his ability to work or engage in normal activities of daily living, this opinion must be curtailed to the objective findings noted at time of exam and historical laboratory results, as NOT significant to impact his activities of daily living at home or work. Another VA examination dated November 2019 was provided by Dr. J.F. who stated that the Veteran is currently gainfully employed and has been for the past 35 years. Dr. J.F. also stated that the Veteran denied any history of suspensions or disciplinary action. Moreover, Dr. J.F. stated that the Veteran reported restricted social activity, and absence of friendships, social activities, anxiety, depression and low self-worth, when he perceives others staring at him, due to his skin condition. Specifically, the Veteran reported symptoms of depressed mood, anergia, anhedonia, social isolation, difficulty falling and staying asleep, insomnia, low self esteem and feelings of hopelessness/helplessness as being secondary to his service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne. Analysis As noted in the procedural history above, in September 2015, the Board remanded the case for additional consideration by the Director of Compensation Service to determine whether an extraschedular disability rating was warranted under 38 C.F.R. § 3.321 (b). In November 2015, the Director of Compensation and Pension determined that extraschedular consideration was not warranted as the Veteran’s skin disability is not so unusual or exceptional as to render the use of the regular schedular standard impractical. After a referral has been made and the Director of the Compensation and Pension Service has made a determination regarding entitlement to an extraschedular rating, the Board has jurisdiction to review that determination on a de novo basis. See Anderson v. Shinseki, 22 Vet. App. 423 (2009). There is no restriction on the Board’s de novo review of an extraschedular rating once the Director determines that an extra-schedular rating is not warranted. See Wages v. McDonald, 27 Vet. App. 233, 239 (2015). The Director’s decision is not evidence, but, rather, the de facto AOJ decision, and the Board must conduct de novo review of this decision. See Kuppamala v. McDonald, 27 Vet. App. 443, 458 (2015) (the Board reviews the entirety of the Director’s decision de novo and is thus authorized to assign an extraschedular rating when appropriate); see also Smiddy v. Wilkie, 32 Vet. App. 350 (2020). However, based on the evidence of record, the Board agrees with the Director’s opinion in this case. An extraschedular evaluation is to be applied to an individual service-connected disability when the disability is so exceptional or unusual that it makes application of the regular rating schedule impractical. See 38 C.F.R. § 3.321 (b). The Board finds this is not the case for the Veteran’s service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne. The Board has considered the Court’s instruction to consider the Veteran’s contention that he is entitled to an extraschedular rating because his skin disabilities also “cause [his] feelings and emotions to become in a depression state of mind when [he is]out in the public, at a social function, with family, or at work because people stare at [him]for not having normal skin condition.” (April 2, 2013 Letter from Appellant to VA)). As noted in this decision, the Board has acknowledged and considered these symptoms and determined service-connection for dysthymic disorder is warranted. As such, the Board finds VA will adequately compensate the Veteran for any psychiatric and/or mental health effects of his skin disabilities through that rating for his now service-connected dysthymic disorder. Therefore, the Board will not consider these symptoms in assigning the rating. In this case, the Board has found the Veteran’s disabilities do not break from the “governing norm,” as most of his symptoms are expressly contemplated by the rating schedule. As such, the Veteran’s service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne do not satisfy the first criteria for the assignment of an extraschedular rating, as the conditions do not present such an exceptional or unusual disability picture that render the available schedular evaluations inadequate. With respect to the first prong of Thun, the Board acknowledges that the Veteran reported symptoms such as scaling, discoloration, decreased pigmentation, increased pigmentation, rashes, peeling skin, itching, and dryness which are contemplated by the rating schedule. The Veteran treated his skin disability with topical solution, topical steroids, oral antibiotics, and incision and drainage. The Veteran reported that he is entitled to an extraschedular rating because he experiences non-dermatological symptoms which include being unable to remain outside for a prolonged time because sunlight aggravated his skin disability and having to work the night shift to limit exposure to the sun. The rating criteria contemplate the area of the body affected by the skin disability, the type of therapy, scar residuals, size, location, limitation of motion. The additional reports of non-dermatological symptoms do not present an exceptional disability picture warranting an extraschedular rating as the Veteran’s experiences are not unique, unusual, or exceptional for those who have these skin conditions. Moreover, while all of the Veteran’s reported non-dermatological symptoms are not explicitly listed within the rating criteria, the fact that the exact symptoms are not expressly listed within the various diagnostic codes does not render the rating schedule inherently inadequate because the rating schedule is meant to represent the average impairment in earning capacity caused by the condition. 38 U.S.C. § 1155, see also Thun, 22 Vet. App. at 114. The Board acknowledges the additional non-dermatological symptoms that the Veteran experiences, however the Board finds that the current assigned ratings adequately compensate for the Veteran’s overall disability picture. Even when taking into consideration the Veteran’s report of non-dermatological symptoms and all of the evidence of record in the instant appeal, the Board does not find that the evidence establishes an exceptional disability picture as to render the schedular criteria inadequate. See Thun, 22 Vet. App. at 115; see also Long v. Wilkie, 2020 U.S. App. Vet. Claims LEXIS 2371 (2020). With respect to the second prong of Thun, this element is not met. Although the Veteran has reported interference with employment and a single VA examiner has indicated that the Veteran’s skin disability significantly impacted his ability to work, the preponderance of the evidence, including the Veteran’s reports of full-time employment and subsequent VA examination reports, is against a finding that the Veteran’s symptoms caused marked interference with employment. The Veteran stated that he had to work the night shift to limit exposure to the sun. Although the September 2009 VA examiner found that his employment was significantly impacted, the May 2005, August 2013, and June 2015 VA examiners found that the Veteran’s skin disability did not impact his ability to work. The Board acknowledges the April 2006 US Department of Labor form completed by Dr. R.R.; however, Dr. R.R. indicated that the Veteran needed to take no more than 11 days off work per year for medical appointments. The Board does not find that taking 11 days off work per year for medical appointments to be significant and therefore, this minimal time off does not equate to “marked interference with employment”. (Continued on the next page)   Moreover, as detailed above, both November 2019 VA examiners conducted a thorough review of the record and took into consideration the Veteran’s reports of how his disability impacted his employment, but ultimately concluded that the Veteran’s disability did not significantly impact his activities of daily living at home or work. The Board finds that the examiners thoroughly reviewed the claims file and discussed the relevant evidence, considered the contentions of the Veteran, and provided supporting rationales for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board finds that the evidence overwhelmingly reflects that the Veteran did not experience “marked interference with employment” due to his service-connected skin disabilities. Particularly, the Board highlights the fact that the November 2019 VA opinion provided by VA examiner Dr. J.F. states that Veteran has maintained gainful employment for the past 35 years. Thus, the Board concludes that the medical evidence of record does not reveal “marked interference with employment.” In addition, there is no indication in the record that the Veteran was hospitalized because of his skin disability. Based on the evidence of record, the Board finds that the Veteran’s skin disabilities do not warrant an extra-schedular rating as they are not so exceptional to deem the schedular evaluation impractical. As the weight of the evidence is against this claim, the “benefit of the doubt” rule is not for application, and the Board must deny the claim of an extraschedular rating. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran’s claim of entitlement to an extraschedular rating for his service-connected skin disabilities, discoid lupus erythematosus and folliculitis of the facial area, facial scars, and acne prior to September 25, 2009 and since September 25, 2009 are denied. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dorsey-Kwansa, 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.