Citation Nr: 21025248 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 17-03 703 DATE: April 27, 2021 ORDER Entitlement to service connection for a skin disability is granted. FINDING OF FACT Resolving all doubt in the Veteran’s favor, the Veteran’s skin disability began during active service or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for a skin condition have been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the United States Navy from October 1962 to June 1992. The Board thanks the Veteran for his thirty years of service to our country. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In October 2019 and December 2020, the Board remanded the Veteran’s claim for further development. In this regard, the Board must apologize to the Veteran for the delays in the full adjudication of his claim. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.902(c). 38 U.S.C. § 7107(b)(1). Entitlement to service connection for a skin disability The Veteran seeks entitlement to service connection for a skin disability, which he claims manifested in service and has continued since service. Generally, to prevail on a claim of service connection on the merits, there must be competent evidence of (1) a current disability, (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury, and (3) medical evidence or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, service connection may also be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Importantly, the Veteran bears the burden of presenting and supporting his claim for benefits. See 38 U.S.C. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Initially, the Board acknowledges its prior decision from October 2019, which recharacterized the Veteran’s claim for service connection for hyperpigmentation on the forehead, to service connection for a skin disability in order to better reflect the total disability picture of the Veteran’s skin condition. Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (a claim should not be limited to the disorder as characterized by the Veteran but must be characterized and addressed based on the reasonable expectations of the non-expert claimant and the evidence in processing the claim). As such, since service, the Board notes the Veteran has been diagnosed and/or treated for a benign seborrheic keratosis neoplasm manifested as multiple pigmented nevus (i.e., moles) on the mid and lower back. See Naval Hospital Pensacola Private Treatment Records, from August 2006. Jock itch (i.e., tinea cruris). See Id., from February 2007 and January 2019. Hyperpigmentation in the groin/scrotal area. See Id., from February 2007. Unspecified hypertrophic and atrophic conditions of the skin manifested and treated as skin tag removals on the upper back and left anterior-lateral neck. See Id., from July 2007. Inflammatory dermatosis (i.e., atopic dermatitis). See Id., from August 2008, November 2012 and August 2018. Skin abscess of the head requiring incision and drainage of an extraoral lesion. See Id., from November 2010. Benign skin neoplasm pigmented nevus manifesting as multiple moles on face, back and chest. See Id., from November 2011. As well as, a cutaneous abscess of his buttock requiring incision and drainage of a skin abscess resulting in removal of small amount of skin. See Id., from February 2018. Thus, the Board finds the Veteran’s private treatment records provide competent, credible and probative evidence to establish a current skin disability exists for this Veteran. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (Board erred in failing to address pre-claim evidence in assessing whether a current disability existed, for purposes of service connection, at the time the claim was filed or during its pendency). As such the first element of service connection is met, a current disability. Turning to the Veteran’s service treatment records (STR’s), the Board notes with regard to the non-existent entrance medical examination from the Veteran’s service record, the Board does not feel a remand is warranted in this case, for reasons outlined below. As such, the Board recognizes it has a heightened duty to consider the application benefit-of-the-doubt rule when service records are unavailable. See O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). However, this heightened duty does not change the legal standard for establishing a service connection claim. See Russo v. Brown, 9 Vet. App. 46, 51 (1996). The Veteran’s STR’s show that in July 1966, he was diagnosed with “early tinea cruris” (i.e., jock itch). In April 1971, STR’s show the Veteran was found to have a nevus (i.e., mole) manifested as a pigmented papule on the back of his neck requiring a skin biopsy and resulting in a diagnosis of angiokeratoma. STR’s from November 1974 and January 1978 show the Veteran was treated for athlete’s foot (i.e., tinea pedis) that had been long standing and unresponsive to localized treatment of tinactin potassium permanganate or desenex ointment. In November 1985, STR’s show the Veteran developed dark pigmented spots on his forehead three months prior to that date. The examiner noted a provisional diagnosis of actinic keratosis and found the lesions on the frontal scalp almost in the midline, but no need for surgical intervention or biopsy. In February 1986, the Veteran was seen for follow up and the examiner noted that his linear hyperpigmentation was still present on the right side (midline), but still adjudged the matter needed no further medical action as it appeared to be a mole. In July 1986, the Veteran presented with a linear patch of hyperpigmentation over the frontal scalp immediately to the right of the midline. He was diagnosed with linear nevus, but the examiner noted the Veteran had no response to various topical modalities over prior year. Also, the examiner reported the Veteran developed another black, flat, linear, macular lesion over the bony arch of his right cheek that was biopsied and diagnosed as intradermal nevus (moles) while in service. Thus, the competent and most probative evidence of record shows the Veteran had incurrences of a skin condition during service. The question before the Board in this case is whether any of the Veteran’s current skin disabilities are related to his service, to include any of the noted in-service incurrences. In this regard, the Veteran was afforded a VA skin examination in August 2014. The Veteran denied any skin lesions on his scalp or forehead. The examiner noted there were no skin lesions visible on his scalp. The examiner otherwise found the examination unremarkable and noted the Veteran had not been receiving treatment for the same in the previous 12 months. The examiner opined that it was less likely than not that the Veteran’s hyperpigmentation spots on the scalp were incurred in or caused by the claimed in-service injury, event, or illness because there were no spots on his scalp and the intradermal nevus from service had either fully excised or resolved on its own. The Board found the August 2014 VA opinion inadequate in a prior decision because the examiner did not consider the Veteran’s reported symptoms and service medical history when rendering an opinion on the etiology of the Veteran’s skin condition(s). See D’Aries v. Peake, 22 Vet. App. 97, 104 (2008) (“An opinion is adequate where it is based upon consideration of the veteran’s prior medical history and examinations and also describes the disability in sufficient detail so that the Board’s ‘evaluation will be a fully informed one.’“ (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)); see also October 2019 BVA Decision. Thus, the Board affords the August 2014 VA opinion little probative weight in the present claim. The Veteran was next afforded another VA skin examination in September 2020. The examiner noted there were no skin lesions visible on the Veteran at the time of the examination. Notably, the examiner also found that the Veteran previously had a malignant neoplasm which completely resolved and no longer required treatment of any type. The examiner also found that the Veteran had not been treated with medication in the past 12 months for the condition. In October 2020, the physician who conducted the September 2020 examination opined that the Veteran’s reported tinea unguium (i.e., athlete’s foot), dermatitis and tinea cruris (i.e., jock itch) are less likely than not incurred from service based on (in-service) clinical notes from April 1971, November 1985, and July 1986, because, according to the examiner, the earliest mention of the conditions were February 2020, August 2018 and January 2019, respectively. The Board found the October 2020 VA opinion inadequate in a prior decision because the etiology opinions provided on tinea unguium, dermatitis and tinea cruris were based on an inaccurate factual history. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (if the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely); see also December 2020 BVA Decision. Specifically, there is competent, credible and probative evidence showing the Veteran had onset of athlete’s foot in 1974 through 1978 as “long-standing problem” during his military service. Moreover, the Veteran was diagnosed with jock itch and dermatitis earlier than reported by the examiner. Thus, the Board affords the October 2020 VA opinions little probative weight. An addendum VA opinion was then requested and rendered in January and February 2021. The February 2021 VA examiner opined the Veteran’s skin condition is less likely than not due to service. In support, the examiner cited to multiple instances of dermatological issues in service, the two VA examinations in August 2014 and September 2020 where the Veteran did not present with a skin disability, the fact that any past diagnoses are presumed to have resolved, and the fact that a subcutaneous cyst found in February 2019 occurred more than thirty years after the last in-service complaint. The Board finds the February 2021 VA opinion is inadequate to form the basis of a denial of the Veteran’s claim in this case. Specifically, while it cites to the Veteran’s service record, it only mentions the single February 2019 flare up of a subcutaneous cyst in the rationale. Moreover, the report does not provide an opinion for any other noted diagnosis for the Veteran’s skin disability, to include documented evidence of in-service and post-service symptoms of nevus on the Veteran’s chest, back, neck and/or face, as early as 1971, as well as athlete’s foot with onset as a chronic in-service condition from 1974 to 1978, and jock itch appearing in the record as early as 1966, as well as other noted conditions. Thus, the Board affords the February 2021 VA opinion little probative value because it failed to consider the Veteran’s full medical history in rendering an opinion on etiology. See D’Aries, supra. While the three medical opinions are inadequate, the Board has decided not to prolong this appeal by remanding for a third time to obtain another medical opinion addressing the etiology of the Veteran’s skin disability. In reaching this conclusion, the Board has not overlooked the fact that the August 2014, September 2020 and February 2021 VA examiners opined that the Veteran’s skin disability was not due to his service. However, each opinion was based on an incomplete disability picture of this Veteran’s skin condition and failed to address much of the current aspects of his current skin disability. The Board notes that the Veteran’s service treatment records competently and credibly indicate that he suffered from multiple skin disorders during service. Moreover, his lay statements and post-service private treatment records competently and credibly report that he continued to have similar skin condition symptomatology after leaving service. Therefore, the Board finds the Veteran’s service record on board Navy ships, along with his service and post-service medical treatment records, statements made by treating physicians in the record, as well as lay statements made by the Veteran of his symptoms, to be competent, credible and highly probative in this matter and indicate a link between the in-service injury and the post-service disability that the Board cannot ignore in this claim. (Continued on the next page)   As such, all reasonable doubt is resolved in the Veteran’s favor and the claim is granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As the evidence is in relative equipoise, the claim must be decided in the Veteran’s favor. Under such circumstances and with granting the Veteran the benefit of any doubt in this matter, the Board concludes that service connection for a skin disability is warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). The nature and extent of the problem is not before the Board at this time. John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Davidson 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.