Citation Nr: 21025118 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 19-28 514 DATE: April 27, 2021 REMANDED Service connection for a skin disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from December 1967 to July 1969, including service in the Vietnam War. The Veteran testified before the undersigned Veterans Law Judge during a 2019 hearing. This matter is on appeal from a March 2018 rating decision. In a January 2021 decision, the Board remanded this issue to afford the Veteran a VA examination. The Board will discuss the compliance of the Agency of Original Jurisdiction (AOJ) with its instructions below. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Service connection for a skin disability is remanded. Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was afforded a VA examination for skin diseases in January 2021. The clinician opined that it was less likely than not that the Veteran’s skin disability was proximately due to or the result of his service-connected posttraumatic stress disorder (PTSD), but did not opine as to whether the skin disability had been aggravated by the PTSD. To be adequate, a VA opinion must provide separate rationales for both causation and aggravation. Atencio v. O’Rourke, 30 Vet. App. 74 (2018). A remand is therefore warranted to obtain an additional medical opinion. The matter is REMANDED for the following action: 1. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of his skin disability. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current skin disability had its origin in service or is related to the Veteran’s active service, including exposure to herbicides. b. Whether it is as least as likely as not that any current skin disability was caused by the Veteran’s service-connected PTSD. c. Whether it is as least as likely as not that any current skin disability was aggravated beyond its natural progression by the Veteran’s service-connected PTSD. The clinician is advised that service connection can be established due to herbicide exposure by direct proof of causation, and that it is insufficient to conclude that there is no direct causation simply because the Veteran’s skin disability is not on the list of diseases and conditions that are presumptively associated with exposure to herbicide agents. Although an independent review of the claims file is required, the Board calls the clinician’s attention to the following: a. A December 2016 VA treatment record nothing the Veteran’s report of pruritus of both upper extremities, with examination findings of excoriation and a diagnosis of pruritus. b. The Veteran’s statement in his June 2018 Notice of Disagreement (NOD) that his skin disability has been continuous since active duty service and that there “is no genetic reason for his current skin disorder.” c. A June 2018 VA treatment record noting the Veteran’s report of ongoing intermittent itching and burning in his legs since his service in Vietnam. d. The Veteran’s attorney’s contentions in the January 2020 substantive appeal (VA Form 9) that a “link between dioxin exposure and skin disorders is medically well established” and that “medical studies support a nexus connection between PTSD and dermatologic symptoms, including excoriation and pruritus.” e. A May 2017 article, the abstract of which was submitted by the Veteran in January 2020, titled “Posttraumatic stress disorder (PTSD) and the dermatology patient.” The rationale for any opinion expressed should be provided. Note that a lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why this is so. 2. Ensure that the directives specified in this remand have been implemented.  If they have not, appropriate corrective action must be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998). 3. Then, readjudicate the claim. If the decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ryan Frank, 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.