Citation Nr: 21024315 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 10-33 658 DATE: April 22, 2021 ORDER Entitlement to service connection for a respiratory disorder, to include asthma and chronic obstructive pulmonary disease (COPD), as due to herbicide exposure and the service-connected posttraumatic stress disorder (PTSD), is granted. Entitlement to service connection for hypertension, to include as due to herbicide exposure and the service-connected PTSD, is granted. Entitlement to service connection for a skin disorder, to include rash of the hands and upper body, and as due to herbicide exposure and as due to in-service sun exposure, granted. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, the Veteran’s respiratory disorder is related to service. 2. Resolving reasonable doubt in the Veteran’s favor, the Veteran’s hypertension is related to service. 3. Resolving reasonable doubt in the Veteran’s favor, the Veteran’s skin disorder is related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a respiratory disorder are met. 38 U.S.C. §§ 1101, 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. The criteria for service connection for hypertension have are met. 38 U.S.C. §§ 1101, 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 3. The criteria for service connection for a skin disorder are met. 38 U.S.C. §§ 1101, 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1965 to October 1969, to include a tour on land in the Republic of Vietnam during the Vietnam era. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran provided testimony at a December 2020 videoconference hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is associated with the claims folder. Procedurally, the claims were remanded by the Board in February 2014 and October 2014 for additional development. In March 2016, the Board denied the claims on appeal. The Veteran appealed the denials to the United States Court of Appeals for Veterans Claims (Court). In a January 2017 Joint Motion for Remand (JMR), the parties agreed that the Court should vacate and remand the Board’s March 2016 denials of the issues currently on appeal. (The March 2016 Board decision also addressed service connection for arthritis, but that issue has been dismissed by the Court.) Thereafter, in August 2017, the Board remanded the issues for further development. In March 2019, again the Board remanded the claims due to inadequacies with a November 2017 VA examination. Specifically, the VA examiners failure to address lay assertions and various treatise cited by the Veteran. The RO has provided the same inadequacies in the more recent VA examination. Upon reconsideration of all of the evidence of record and in view of the futility of making further attempts to remedy repeated inadequacies in the medical evidence, the Board finds the evidence is in equipoise to support a grant of service connection for all three claims. As such, the Board will proceed with the merits of the appeal. Service Connection 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: (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); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis for a disability that is shown to be 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) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). In addition, for certain chronic diseases, such as hypertension, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307, 3.309(a). When a chronic disease is not shown within one year after service, under 38 C.F.R. § 3.303 (b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. §§ 3.303 (b), 3.309(a); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA regulations require that hypertension or isolated systolic hypertension be confirmed by readings taken two or more times on at least three different days. For compensation purposes, hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101. VA has established a presumption of exposure to herbicide agents applicable to veterans who served in the Republic of Vietnam during the Vietnam War, and a presumption of service connection applicable to veterans who are either presumed to have been exposed to herbicide agents, or who are shown to have been actually exposed to herbicide agents during service. The term “herbicide agent” means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. 38 C.F.R. § 3.307 (a)(6)(i). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. “Service in the Republic of Vietnam” includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307 (a)(6)(iii). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307 (a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of § 3.307(d) are also satisfied. AL amyloidosis, chloracne or other acneform disease consistent with chloracne, type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin’s disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin’s lymphoma, Parkinson’s disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). 38 C.F.R. § 3.309 (e). The herbicide-presumptive diseases shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and early-onset peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307 (a)(6)(ii). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 1. Entitlement to service connection for a respiratory disorder The Veteran claims his respiratory disorder is related to service. Specifically, he alleges it is related to herbicide exposure or the service- connected PTSD. Based on the reasons discussed below, the Board will resolve doubt in the Veteran’s favor and grant service connection. Service treatment records (STRs) reflect a November 1968 upper respiratory infection and chest pain complaints. On the October 1969 separation examination, normal clinical findings were noted for the chest and lungs. In a February 2010 statement the Veteran’s brother indicated the Veteran’s asthma began upon his return from service and has continued since that time. He stated the Veteran had shortness of breath and difficulty breathing which resulted in treatment for asthma like symptoms. An April 2014 VA examination report indicated review of the Veteran’s claims file, recounted the Veteran’s history, and recited his complaints. The examiner opined the Veteran’s asthma was less likely than not incurred in or caused by service. It was reasoned there is no evidence that the Veteran had treatment for or diagnosed with asthma while in service. It was noted “one episode of coughing with wheezing after service is not consistent with a diagnosis of asthma. There must be multiple episodes with treatment and preferably with abnormal PFTs.” As it relates to herbicide exposure the examiner noted herbicide exposure would have caused immediate symptoms not symptoms later on. It was noted, “PTSD is not known to cause or aggravate the course of asthma past its natural progression.” The examiner also opined the condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by service. It was reasoned, there is no medical basis for the claim that PTSD would aggravate asthma beyond its natural progression. An August 2014 private opinion from Dr. M.R. indicated the Veteran had been under his care for the last twenty-three years for, in pertinent part, asthma. The physician opined that the Veteran’s early onset of symptoms at a very young age after his return from service could only be consistent with Agent Orange syndrome. No rationale was provided. In a February 2015 VA addendum opinion, the examiner opined the Veteran’s asthma was less likely than not incurred in or caused by service. It was also opined the asthma was less likely than not proximately due to or the result of a service-connected disability. It was reasoned, PTSD does not cause asthma or aggravate it as a link does not connotate cause and effect. Furthermore, it was noted asthma is not compensable due to herbicide exposure per VA guidelines. A May 2017 private opinion from Dr. M.R. indicated the Veteran’s respiratory disorder is a direct side effect of exposure to chemical Agent Orange. No rationale was provided. In a November 2017 VA addendum opinion, the examiner opined, it is less likely that the Veteran’s current asthma had its onset in service or is otherwise related to his active military service. It was also opined it is less likely that the Veteran’s current COPD had its onset in service or is otherwise related to his active military service. It was reasoned, the Veteran’s symptoms of chest pain and URI noted in service are not signs or symptoms of, nor predisposing sign and symptoms of, nor specific signs of asthma. Also, there are no other clinical notes in the STR regarding respiratory symptoms. The examiner reviewed and noted the treatise evidence included in the November 2013 IHP as well as statements from the Veteran’s brother. It was noted the Veteran was not diagnosed with asthma until 1995. A December 2019 VA examination report indicated review of the Veteran’s claims file, recounted the Veteran’s history, and recited his complaints. He was diagnosed with asthma and COPD. The examiner opined the condition claimed is less likely than not proximately due to or the result of Veteran’s service. As it relates to the asthma, it was reasoned, The Veteran was diagnosed with asthma in 1970. There is documentation that shows that Veteran was treated for acute upper respiratory infections and colds during military service which resolved. There is no diagnosis of asthma during service years. Veteran’s separation exam notes normal respiratory examination. Military records show that service were from 1966 to 1968, but asthma was diagnosed in 1970. There are private medical records and VA medical records show that Veteran was diagnosed with mild asthma which was well controlled with inhaled albuterol as needed. In addition, asthma is not one of the diseases that is associated with exposure to agent orange. Currently diagnosed asthma may be secondary to allergies which were documented, and his provider had recommended a consultation with allergist. As it relates to COPD, it was reasoned, the Veteran was diagnosed with COPD in 1970 and there were no signs or symptoms of COPD during his service years. It was noted, “there is [a] statement from VA outpatient clinic in Boca that on his CXR, there were changes of COPD from previous history of smoking, no acute disease.” It was further noted, although the Veteran had one incident of chest pain and URI during active duty, this does not constitute a diagnosis of COPD. URI occurs in persons without these underlying chronic lung diseases. Veteran’s brother did indicate a “lung problem” after return from Vietnam. This term is very nonspecific and can be used to describe many different health conditions not even released to the lungs. For example, they can mean shortness of breath from panic attacks, or secondary to smoking or nasal congestion from his sinus condition. Furthermore, there is no evidence that [the] Veteran’s COPD has been aggravated beyond nature progression since there is no evidence documented demonstrating pulmonary hypertension, severe COPD requiring oxygen or asthma that requires daily medications. [The] Veteran has inhalers that he takes as needed for both conditions. There is no medical evidence that supports that PTSD can cause asthma or COPD. In the remarks section the examiner opined, “the Veteran’s reported symptoms of chest pain, palpitations and difficulty breathing are at least as likely as not due to secondary to conditions already diagnosed such as PTSD, asthma, and COPD, and less likely than not related to heart conditions.” The examiner also provided an opinion to address conflicting medical evidence. It was opined the Veteran’s PTSD is most likely not masking underlying respiratory condition in or since service. It was reasoned, COPD is a preventable chronic condition best characterized by measurable, nonreversible restrictions in air flow with repeated, intermittent exacerbation of symptoms generally manifested by shortness of breath, nonproductive cough, sensations of air hunger, and reduced capacity for physical activity. It was noted, due to the objectivity of this condition, even with PTSD, it is possible to diagnose this condition. Shortness of breath or labored breathing are both common to PTSD and COPD, but only COPD can be objectively measured so it can be easily distinguished from PTSD which would yield normal lung function tests. Since this Veteran has had several PFT’s performed, it is easy to differentiate symptom etiology. During the December 2020 Board hearing the Veteran testified to in-service treatment for breathing problems right after his return from Vietnam. The breathing problems continued after service. The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations and finds the current disability is related to service. Initially, the Board notes the Veteran served in Vietnam during the qualifying period and herbicide exposure is therefore presumed. Asthma and COPD are not among the diseases subject to presumption as listed in 38 C.F.R. § 3.309(e). However, when service connection cannot be granted on a presumptive basis, the Veteran may still establish service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Upon review of the evidence in conjunction with applicable laws and regulations, and for the reasons explained below, the evidence is relative equipoise as to whether the Veteran’s respiratory disorder is related to service. The Board finds it is at least as likely as not that the Veteran’s current respiratory disorder developed during service. STRs reflect a November 1968 upper respiratory infection and chest pain complaints. Furthermore, although the December 2019 VA examiner provided a negative etiology opinion, as part of the rationale the examiner incorrectly found the Veteran left service in 1968 and was diagnosed with asthma two years later. However, the Veteran left service in October 1969. This is significant because 38 C.F.R. § 3.3039(d) permits service connection for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. In this case the Veteran and his brother have provided statements indicating the Veteran was treated for breathing problems during and shortly after service and the symptoms have persisted to this day. Furthermore, although there is no rationale, the August 2014 and November 2017 private treating physician, Dr. M.R., opined the condition was related to service. Therefore, the Veteran’s in-service respiratory infection and post- service asthma diagnosis coupled with the unrefuted statements that the Veteran has in fact suffered from breathing problems in-service provides evidence in support of a grant. Accordingly, service connection for a respiratory condition is warranted. 2. Entitlement to service connection for hypertension The Veteran claims he suffers from a hypertension disability related to herbicide exposure, or the service-connected PTSD. Based on the reasons discussed below, the Board will resolve doubt in the Veteran’s favor and grant service connection. STRs do not reflect any symptoms, diagnosis, or treatment for a hypertension. On the October 1969 separation examination, the Veteran’s blood pressure read 140/88. Post service, in March 1995, the Veteran was diagnosed with hypertension. An April 2014 VA examination report indicated review of the Veteran’s claims file, recounted the Veteran’s history, and recited his complaints. The examiner opined the Veteran’s hypertension was less likely than not incurred in or caused by service. It was reasoned there is no current policy to award service connection for herbicide exposure. An August 2014 private opinion from Dr. M.R. indicated the Veteran had been under his care for the last twenty-three years for, in pertinent part, hypertension. The physician opined that the Veteran’s early onset of symptoms at a very young age after his return from service could only be consistent with Agent Orange syndrome. No rationale was provided. In a February 2015 VA addendum opinion, the examiner opined the Veteran’s hypertension was less likely than not proximately due to or the result of a service-connected disability. It was reasoned, there is no evidence that PTSD “causes” or “aggravates” hypertension as there is only an association. Furthermore, it was noted “there is no evidence that herbicide exposure causes or aggravates hypertension and there is no current policy to award service connection for herbicide exposure.” A May 2017 private opinion from Dr. M.R. indicated the Veteran’s hypertension is a direct side effect of exposure to chemical Agent Orange. No rationale was provided. In a November 2017 VA addendum opinion, the examiner opined, it is likely that the Veteran’s current hypertension was incurred during active duty or presumed service connection due to Agent orange exposure. It was reasoned, the hypertension was diagnosed in 1995 and the Veteran’s private doctor indicated he has been treating the Veteran for 26 years. It was also opined it is less likely that the Veteran’s hypertension was caused or aggravated beyond its natural progression by his service-connected PTSD. It was reasoned the hypertension was not aggravated because the Veteran had no early complication such as coronary artery disease, cerebrovascular accident, malignant hypertension, congestive heart failure, or chronic kidney disease. A December 2019 VA examination report indicated review of the Veteran’s claims file, recounted the Veteran’s history, and recited his complaints. He was diagnosed with hypertension. The examiner opined the condition is less likely than not proximately due to or the result of the Veteran’s service. It was reasoned, The Veteran’s [hypertension] was diagnosed in 1995 which is several years after discharge from service. There is also documentation from his private doctor from 2013 that states that Veteran was treated by him for 26 years and furthermore private doctor first treated Veteran for [hypertension] in 1995. Veteran does have PTSD which can predispose to hypertension, but this is only thought of as only an association between PTSD and hypertension. This is merely an association and there is lack of evidence to establish causality between the two. PTSD can certainly cause transient hypertension, but not permanent. [The] Veteran does not have other conditions such as heart disease, kidney disease, CVA, or coronary artery disease from previous medical records to states that hypertension can be secondary to these listed conditions. However, there is causality associated between weight gain, improper diet which includes increased amounts of sodium intake that causes hypertension. During previous medical evaluations, providers have advised veteran to lose weight and reduce sodium intake. On the documentation from 10/29/2010, Veteran was advised to maintain weight control and salt restricted diet. As it relates to secondary service connection, the examiner opined, the claimed condition is less likely than not proximately due to or the result of the service-connected condition. It was reasoned, “there is no service-connected condition that is causing a secondary complication or condition, including the Veteran’s hypertension, asthma, or COPD.” The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations and finds the current disability is related to service. Initially, the Board notes the Veteran served in Vietnam during the qualifying period and herbicide exposure is therefore presumed. Hypertension is not among the diseases subject to presumption as listed in 38 C.F.R. § 3.309(e). However, when service connection cannot be granted on a presumptive basis, the Veteran may still establish service connection on a direct basis. See Combee, 34 F.3d at 1042. Upon review of the evidence in conjunction with applicable laws and regulations, and for the reasons explained below, the evidence is relative equipoise as to whether the Veteran’s hypertension is related to service. The Board finds it is at least as likely as not that the Veteran’s current hypertension is related to active duty service. Although the Veteran was not treated for hypertension in service, the October 1969 separation examination reflected an elevated blood pressure reading. Furthermore, although the December 2019 VA examiner provided a negative etiology opinion, the examiner did not discuss the National Academies of Science, Engineering and Medicine (NAS) study indicating there is sufficient evidence of a relationship between hypertension and herbicide exposure. The March 2019 Board decision required the RO to address the study in discussing if the Veteran’s hypertension was related to service, however, the VA examiner did not acknowledge the study. The VA examiner did not discuss the impact, if any, that study has on the Veteran’s hypertension claim. Therefore, the Board finds the VA examination opinion is inadequate. Furthermore, although there is no rationale, the August 2014 and November 2017 private treating physician, Dr. M.R., opined the condition was related to service. Therefore, the Veteran’s in-service blood pressure readings and post- service hypertension diagnosis coupled with the herbicide exposure and the NAS study indicating there is sufficient evidence of a relationship between hypertension and herbicide exposure, provides evidence in support of a grant. Accordingly, service connection for hypertension is warranted. 3. Entitlement to service connection for a skin disorder The Veteran claims he suffers from a skin disorder related to herbicide exposure, or in-service sun exposure. Based on the reasons discussed below, the Board will resolve doubt in the Veteran’s favor and grant service connection. STRs reflect a November 1966 complaint of a knot on the left hand and subsequent diagnosis of ganglion. On the October 1969 separation examination, normal clinical findings were noted for the skin. In June 1988 private treatment records, the Veteran reported a recurrent rash of a two-week duration. At the June 2013 Board hearing the Veteran testified that his skin disorder began in service and has continued since that time. He alleged he had discoloring dark circles that would bleed and dry out. An April 2014 VA examination report indicated review of the Veteran’s claims file, recounted the Veteran’s history, and recited his complaints. He was diagnosed with dermatitis or eczema. The examiner opined the Veteran’s skin condition was less likely than not incurred in or caused by service. It was reasoned the Veteran has been treated for hand eczema which was mild during the examination. The spots on his forearm are most likely secondary to his prescribed prednisone. It was noted, there is no evidence of a chronic skin condition in service or shortly after discharge. In a February 2015 VA addendum opinion, the examiner opined the Veteran’s skin disorder was less likely than not incurred in or caused by service. It was reasoned, the Veteran never mentioned a porphyria cutanea tarda condition nor has he been seen by the VA for that condition. The February 2016 statement from Dr. J.F. indicated the Veteran’s diffuse actinic damage to his arms are related to UV exposure as well as suggested relationship to chemical exposure. A May 2017 private opinion from Dr. M.R. indicated the Veteran’s skin disorders are a direct side effect of exposure to chemical Agent Orange and is related to his Vietnam military service. No rationale was provided. In a November 2017 VA addendum opinion, the examiner opined, it is less likely that the Veteran’s eczema was incurred during active duty or presumed in-service herbicide exposure and/or in-service sun exposure. It was reasoned, the Veteran was not seen until 1998 with a chief complaint of recurrent rashes of 2 weeks duration. The STRs do not show complaints, findings, or treatment for rashes or skin lesions. It was noted, private medical record in Nov 2005 noted rashes on the hand due to Percocet and eczema is not included in the list of presumed diseases associated with agent orange exposure. Also, eczema is not caused by sun exposure. A December 2019 VA examination report indicated review of the Veteran’s claims file, recounted the Veteran’s history, and recited his complaints. The Veteran was diagnosed with dermatitis, eczema, and squamous cell carcinoma status post excision. The examiner opined it is less likely that the diagnosed diffuse actinic damage to his arms had its onset or is otherwise related to his active military service. It was reasoned, This opinion takes into consideration the presumed herbicide and sun exposure during military service. In review of pertinent documentation provided by VA, there is no finding that shows that there were any complaints or treatment for diffuse actinic damage. Furthermore, this disease is not listed in the presumed disease list for Agent orange exposure. In addition, Veteran has been exposed to sun before and after service more than if calculated sun exposure only during the 4-year military service. There is no objective evidence that the current skin conditions to include eczema, dermatitis, SCC, keratinization diseases of the skin are associated with service. There is no documentation that these conditions were addressed, evaluated or treated during service years. They manifested several years after discharge from service and so can be attributed to multiple exposures and lifestyle the Veteran has led following discharge from service. The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations and finds the current disability is related to service. Initially, the Board notes the Veteran served in Vietnam during the qualifying period and herbicide exposure is therefore presumed. Skin disorders are not among the diseases subject to presumption as listed in 38 C.F.R. § 3.309(e). However, when service connection cannot be granted on a presumptive basis, the Veteran may still establish service connection on a direct basis. See Combee, 34 F.3d at 1042. Upon review of the evidence in conjunction with applicable laws and regulations, and for the reasons explained below, the evidence is relative equipoise as to whether the Veteran’s skin disorder is related to service. The Board finds it is at least as likely as not that the Veteran’s current skin disorder is related to active duty service. STRs reflect a November 1966 complaint of a knot on the left hand and subsequent diagnosis of ganglion. Furthermore, although the December 2019 VA examiner provided a negative etiology opinion the opinion was based on a lack of in-service diagnosis and sun exposure prior to and after service. The absence of an in-service diagnosis of a skin condition is not dispositive; the question is whether the Veteran’s skin disability is related to service. Furthermore, in noting the Veteran had sun exposure prior to and after service, the examiner failed to address the length of time necessary to develop a skin disorder such as, diffuse actinic damage, dermatitis, eczema, and squamous cell carcinoma status post excision. Therefore, the Board finds the VA examination opinion is inadequate. Furthermore, although there is no rationale, the February 2016 statement from Dr. J.F. indicated the Veteran’s diffuse actinic damage to his arms are related to sun exposure. In fact, the May 2017 private physician Dr. M.R., indicated the Veteran’s skin disorders are a direct side effect of exposure to chemical Agent Orange and Vietnam military service. The Board acknowledges that the Veteran may experience skin rashes or dry skin related to the skin disorders. Indeed, these are common maladies to which laypersons may competently attest. See Jandreau v. Nicholson, 492 F.3d 1372 (2007); see also Barr, 21 Vet. App. 303 (lay testimony is competent to establish the presence of observable symptomatology). During the June 2014 Board hearing the Veteran testified that his skin disorder began in service and has continued since that time. Therefore, the Veteran’s in-service skin disorder diagnosis coupled with the unrefuted statements that the Veteran has in fact suffered from skin rashes and dry skin beginning in service, provides evidence in support of a grant. Accordingly, service connection for a skin disorder is warranted. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Jackman, 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.