Citation Nr: 21023633 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 14-13 943 DATE: April 21, 2021 REMANDED Service connection for skin disorder as secondary to service-connected posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1965 until his honorable discharge in May 1968. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision by the Seattle, Washington, Regional Office (RO) of the United States Department of Veterans Affairs (VA), which denied service connection for skin disorder (also claimed as chloracne due to Agent Orange exposure and jungle rot). In a March 4, 2020, decision, the Board denied the Veteran’s claim for service connection for skin disorder. The Veteran subsequently appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). The parties submitted a Joint Motion for Partial Remand (JMPR) in which they stipulated the Board failed to address the Veteran’s theory that his skin disorder was secondary to his service-connected PTSD. The parties also stipulated that “Appellant does not appeal the Board’s denial of entitlement to service connection for a skin disorder on a direct basis and on a presumptive basis based on exposure to herbicides. Accordingly, the Board’s decision as to those issues should remain undisturbed, and the appeal with respect to those issues should be dismissed.” The Court entered an order in November 2020 vacating the Board’s decision in part and remanding the matter to the Board for readjudication, consistent with the parties’ JMPR. The case now returns to the Board for readjudication. The Board notes that the Veteran primarily relied on theories of direct and presumptive service connection for his claim for service connection for his skin disorder. As the parties have stipulated that the Board’s March 2020 decision denying service connection on those theories is not to be disturbed, that decision is final as to those theories of service connection. 38 C.F.R. § 20.1100. Therefore, they are not before the Board on remand. But, as stated within the parties’ JMPR, the Veteran did assert a theory of secondary service connection for his skin disorder based on his service-connected PTSD. See January 2018 and January 2020 Informal Hearing Presentation Briefs. At this time, no medical opinion evidence of record has addressed whether the Veteran’s skin disorder is secondary to his service-connected PTSD. Therefore, the Board finds remand is required to obtain a VA medical examination and opinion on this issue. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Waters v. Shinseki, 601 F.3d 1274, 1277 (Fed. Cir. 2010); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the matter is REMANDED for the following actions: 1. Obtain any of the Veteran’s outstanding VA medical records and associate them with the claims file. 2. After any additional records are associated with the claims file, obtain a VA examination from an appropriately qualified clinician to provide an opinion addressing the onset and etiology of the Veteran’s skin disorder. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion regarding the following: (a.) Please identify each skin disorder the Veteran has experienced during the period on appeal. (b.) For each identified skin disorder, whether it is at least as likely as not (50 percent probability or more) that the Veteran’s skin disorder was caused by (proximately due to or as the result of) his service-connected PTSD. (c.) For each identified skin disorder, whether it is at least as likely as not (a 50 percent probability or more) that the Veteran’s skin disorder was aggravated by his service-connected PTSD. The examiner is advised “aggravation” means an increase in the severity of the underlying disability beyond its natural progression. In rendering his or her opinion(s), the examiner is specifically asked to address the medical literature cited within and attached to the Veteran’s January 2018 appellate brief: (a.) Philip Shenefelt, Psychological interventions in the management of common skin conditions, 3 Psychology Research and Behavior Management, 51, 61 (finding that “[t]he psyche through psychoneuroimmunoendocrine and behavioral mechanisms can in turn have a major impact on skin disorders”) (b.) America Psychiatric Association, Mental Health and Skin Connection, available at https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2017/07/mental-health-and-skin-connection In addition, in rending his or her opinion(s), the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) The Veteran’s PTSD became service connected as of April 24, 1981. (b.) His medical records indicate various potential skin disorders, including dermatitis, pruritic acneiform rash, possible eczema, acneiform lesions, macular hypomelanosis, spongiotic dermatitis, idiopathic guttate hypomelanosis, and tinea versicolor. (c.) Private medical records from 2001 from Dr. I.B., indicating lightening of the skin, prescriptions for acne medication, a diagnosis of seborrheic dermatitis and steroid-induced acne, and residual hypopigmentation. (d.) September 2012 VA Hepatology note that documented a biopsy result of the skin showed a fungal infection versus idiopathic guttate hypomelanosis. (e.) August 2014 VA Dermatology note reporting that the Veteran’s hypopigmented macules are unresponsive to antifungals, topical antibiotics, or hydroquinone. The examiner is reminded to consider the Veteran’s lay statements regarding the nature and onset of any skin disorder, including any evidence concerning continuity of symptomatology. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran’s assertion of a skin disorder in service or the assertion that the Veteran’s service-connected PTSD is related to a skin disorder. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. If the examiner relies on medical treatises, the examiner should identify the treatises. (Continued on the next page)   If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question(s). M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. F. Sawka, 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.