Citation Nr: 21023011 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 20-00 281A DATE: April 19, 2021 REMANDED Entitlement to service connection for a skin condition of the head is remanded. REASONS FOR REMAND The Veteran served honorably from September 1955 to October 1957. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. In July 2020, the Veteran and his wife testified before the undersigned Veterans Law Judge; a transcript of the hearing is of record. In September 2020, the Board remanded the claim for additional records and an examination for an opinion. 1. Entitlement to service connection for a skin condition of the head is remanded. The Veteran was afforded a VA examination in October 2020 in accordance with the September 2020 Board remand instructions, which included: Schedule the Veteran with an appropriate clinician to identify any skin conditions of the head since the date of the claim (June 2017). For each diagnosis, the examiner shall opine as to whether it is at least as likely as not (a 50 percent or greater probability) that such condition is due to service. As there are no STR in the record for review, the examiner must take a careful history of inservice complaints as well as how the scalp issues developed post service. As the Veteran contends that the helmet caused a rash on the scalp and eventual loss of hair, this claim must be addressed by the examiner. The Board finds the VA examiner’s October 2020 opinion is inadequate. In the examination, the examiner notated the Veteran’s complaints of a rash, bumps and blisters in training and diagnosed the Veteran with alopecia. The examiner failed to discuss the complaints in his opinion where he found “[a] review of [the] record does not indicate a skin condition of the scalp or alopecia. There is [a] note [that] indicates Nizoral shampoo for seborrheic dermatitis but location not identified. No chronic diagnosis is made for Alopecia. A Nexus has not been established”. This is seemingly contrary to the examiners finding the Veteran’s use of nizoral shampoo for seborrheic dermatitis and a diagnosis of alopecia. It appears the examiner finds no chronic diagnosis in review of the medical evidence of record which is notably sparse, and the RO found the Veteran’s service treatment records (STRs) were irretrievable as they had been lost in a fire. See July 2009 VA21-3101 Request for Information. The Board instructed the RO to assist the Veteran in obtaining private treatment records from a “Doctor Glenn”. The identification of the physician in question was erroneous in the previous remand. The physician from whom records should be sought are from a Dr. Allan G. Stahl. Review of the Veteran’s claims file notes an attempt to retrieve those records, however, the authorization used to request those records had expired and was thus rejected. See November 2019 Correspondence. The Veteran is reminded that the duty to assist is a two-way street. If the Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the relevant evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The matter is REMANDED for the following actions: 1. Update the record for any VA records. 2. With any necessary assistance from the Veteran, obtain all outstanding private treatment records. These include records from a Doctor Allan G. Stahl who provided treatment from 1997 to 2013. 3. Schedule the Veteran with an appropriate clinician to identify any skin conditions of the head since the date of the claim (June 2017), to include seborrheic dermatitis and alopecia. For each diagnosis, the examiner shall opine as to whether it is at least as likely as not (a 50 percent or greater probability) that such condition is due to service. As there are no service treatment records in the record for review, the examiner must take a careful history of inservice complaints as well as how the scalp issues developed post service. The Veteran contends that the helmet caused a rash on the scalp and eventual loss of hair, and this assertion must be addressed by the examiner, even though there are no records that document these conditions. The Veteran is competent to tell the examiner and VA what happened to him in service and afterwards, even though it is not written in any medical record or other history. Failure to take into account the Veteran’s lay statements will result in an inadequate opinion and the appeal will be returned. 4. A clearly stated rationale for any opinion offered should be provided and must not be based solely on the lack of any evidence of a diagnosis a skin condition of the head in the Veteran’s service treatment records or immediately thereafter. In this regard, a discussion of the relevant facts and medical principles involved would be of considerable assistance to the Board. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kelsey Love, 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.