Citation Nr: 21024286 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 14-19 776 DATE: April 22, 2021 ORDER Entitlement to service connection for psoriasis (claimed as chronic skin condition) is denied. FINDING OF FACT The evidence does not demonstrate that the Veteran’s psoriasis was incurred in service or within one year of military service or is otherwise related to military service. CONCLUSION OF LAW The criteria for service connection for psoriasis are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1971 to April 1972. This case is before the Board of Veterans’ Appeals (Board) on appeal from a November 2014 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that rating decision, the RO denied entitlement to service connection for chronic skin condition. The Veteran’s notice of disagreement was received in January 2015. The RO issued a statement of the case in July 2015. The Veteran’s VA Form 9, substantive appeal to the Board, was received in October 2015. In January 2018 and December 2019, the Board remanded the case to the RO for further development and adjudicative action. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498 (1995). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may also be granted on a presumptive basis for certain diseases associated with exposure to certain herbicide agents, even though there is no record of such disease during service, provided that the disease manifests to a compensable degree any time after service, in a Veteran who had active military, naval, or air service in the Republic of Vietnam and its surrounding off-shore waters during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 U.S.C. §§ 1116, 1116A; 38 C.F.R. §§ 3.307, 3.309(e), 3.313. This presumption may be rebutted by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307, 3.309. Additionally, a Veteran may establish service connection for a disability not on the list of diseases that are presumed to be due herbicide agent exposure with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran contends his chronic skin condition, to include psoriasis, which developed during and after service, is the result of exposure to herbicide agents (Agent Orange) while stationed in Vietnam. See June 2013 and May 2014 Statements in Support. Specifically, the Veteran asserted in an October 2019 Statement in Support: I was in country in Vietnam and there were many related types of herbicides that were not recorded. I was exposed by water intake. They sprayed the surrounding areas. My skin was exposed mostly on my hands, and clothing. We also pulled guard duty at the Tourne Air Base there and that is where they mixed the AO herbicides. We did rotations there for about a week and rotated out with different companies every 3-4 weeks. The Veteran has a current diagnosis of psoriasis. See October 2012 Private Medical Records; January 2020 VA Skin examination. Additionally, based on the Veteran’s DD214 showing service in Vietnam, the VA has conceded exposure to Agent Orange during his service. See November 2014 Rating Decision. The issue in this case is solely whether there is a nexus to military service. The Board, however, finds that the evidence does not demonstrate such a nexus in this case. The evidence of record does not document any diagnosis of arthritis during military service or within one year therefrom. Service connection for that condition on a presumptive basis is therefore denied. 38 C.F.R. § 3.307, 3.309. Furthermore, the separation examination noted a normal examination and the Veteran did not complain of any skin problems at the time of his discharge; rather, the evidence does not demonstrate any complaints for many years after discharge from service. See Maxson v. West, 12 Vet. App. 453 (1999), aff’d, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim, which weighs against the claim). Service connection on the basis of continuity of symptomatology in this case is therefore also denied. 38 C.F.R. § 3.303(b). Psoriasis is not among the statutorily enumerated diseases set forth in VA regulations for which presumptive service connection is available for veterans exposed to herbicide agents during active service. 38 C.F.R. § 3.309(e). Therefore, the presumption under 38 C.F.R. §§ 3.307(a)(6), 3.309(e) does not apply; the Veteran’s psoriasis may not be presumptively linked to herbicide exposure. The Veteran was afforded a VA Skin examination in December 2018. The examiner noted the Veteran was first diagnosed with psoriasis in 2008 and found that his skin condition, to include as due to herbicide exposure, was less likely than not incurred in or caused during service. The examiner reasoned: The medical evidence does not support this claim. The Veteran has a diagnosis of psoriasis that was not made within one year of discharge. He was discharged from the military on 4/18/72. He was diagnosed with psoriasis over 30 years after this. There is no evidence in the [service treatment records] that the Veteran sustained a skin condition while in the military. There is no documentation of a skin condition at the time of separation. The presumptive dermatological conditions of Agent Orange exposure include chloracne and porphyria cutaneous tarda. The Veteran has not evidence of either [of] these two conditions. In addition, there is no evidence this condition started during military service. Service connection on a direct basis is denied. During an August 2019 VA Skin examination, the Veteran reported his chronic skin condition, to include as due to herbicide exposure had its onset 2 weeks after returning from Vietnam at which time, he first began noticing it. He explained it has been chronic, up and down over time, and had two dermatologists in the late 1970s. One dermatologist told him he had chloracne and prescribed him topical treatment which did not help. He subsequently saw other dermatologists who had all diagnosed his skin condition as psoriasis, not chloracne. After examination, the examiner, a VA physician, found the Veteran’s psoriasis was less likely than not incurred in or caused by the claimed in-service injury, to include as due to herbicide exposure, event or illness. The examiner reasoned: The medical evidence does not support this claim. Review of [service treatment records], and 12m’s after active duty military service, reveal no objective evidence of a chronic skin condition, therefore no nexus can be made. A condition must be chronic to warrant service connection. 4/17/72 separation exam – skin normal. Current Agent Orange Presumptive Diagnoses include Chloracne (or similar acneform disease) and porphyria cutaneous tarda and Veteran has neither of these diagnoses. He has chronic psoriasis which is not a current [Agent Orange] presumptive disease. Based on a review of the entire claims file, including all medical evidence, a VA physician provided a January 2020 addendum opinion to specifically address direct service connection in this case. The physician found the Veteran’s psoriasis was less likely than not etiologically related to active service, to include exposure to herbicides. The examiner provided the following rationale: Entire [claims] file reviewed including peer-reviewed articles related to psoriasis. Veteran’s only skin condition is psoriasis which was diagnosed in 2012 which is close to 3 decades after active duty service. [Service treatment records] are silent for this condition and psoriasis is not an agent orange presumptive condition. The weight of the medical literature is against a relationship between exposure to agent orange and psoriasis. Psoriasis is a chronic immune-mediated inflammatory skin disease of unknown origin, whose clinical characteristics vary from patient to patient due to several genetic and environmental factors that have been identified to be related to the pathogenesis of the disease (Griffith, 2007). Four decades of clinical and basic research on psoriasis have elucidated that psoriasis is a skin disease with a spectrum of clinical phenotypes and results from the interplay of genetic, environmental, and immunological factors (Di Meglo, 2014). According to Di Meglo (2014), a recent systematic review of psoriasis epidemiology confirms that psoriasis is a common disease, based on 46 studies reporting prevalence of psoriasis and seven studies related to the incidence of disease in the general population (Paris, et al. 2013). Prevalence is higher in adults (from 0.91% to 8.5%) as compared with children (from 0% to 2.1%) with dual peak incidence: ~30-39 and ~60 years of age. The Veteran was diagnosed with psoriasis in his 60s which is consistent with the epidemiology of the disease. Psoriasis was less likely due to active duty service or due to exposure to agent orange. It is an intervening interceding illness that is at least as likely as not due to age, genetic factors and other environmental factors. In response to the January 2020 rationale, the Veteran’s representative argues, “exposure to herbicides in Vietnam qualifies as environmental causes” for which service connection should be granted. See February 2021 American Legion Appellate Brief Although the Board acknowledges the representatives arguments and Veteran’s statements that his psoriasis is related to his herbicide exposure during service, the Board reflects that neither the Veteran nor his representative are competent to render such an opinion as neither have the requisite medical knowledge or expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). In the instant case, more probative weight is accorded to the competent medical evidence outlined above, which establishes that the Veteran’s psoriasis, is less likely than not etiologically related to active service, to include exposure to herbicides. As the preponderance of the evidence is against the Veteran’s claim for service connection, the benefit of the doubt doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Ardalan, 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.