Citation Nr: 21025273 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 19-18 393 DATE: April 27, 2021 ORDER Entitlement to service connection for discoid lupus erythematosus, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is denied. FINDING OF FACT The current discoid lupus erythematosus disability was not incurred in service, did not manifest to a compensable degree within one year of service, and is not is not caused or aggravated by service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for discoid lupus, to include as secondary to the service-connected PTSD, have not been met. 38 U.S.C. §§ 1110, 1112, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 2004 to February 2005, from May 2006 to September 2006, from November 2006 to April 2007, and from August 2008 to August 2009. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2018 rating decision of the Department of Veterans Affairs (VA). In September 2019, the Board remanded the case for further development. Entitlement to service connection for discoid lupus erythematosus. The Veteran generally asserts that service connection for lupus is warranted, to include as secondary service-connected PTSD. See December 2018 Notice of Disagreement (NOD). Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (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 in or aggravated by service. The Veteran is currently diagnosed with discoid lupus, which is considered a “lupus erythematosus,” recognized as a “chronic disease” under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. §§ 3.303(b), 3.307, and 3.309 apply to the claim for service connection for lupus. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). The Veteran must have served 90 days or more during a war period or after December 31, 1946 for the chronic presumptive provisions to attach. 38 C.F.R. § 3.307(a)(1). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as lupus erythematosus, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 C.F.R. §§ 3.307, 3.309(a). In addition to direct service connection (discussed above), service connection may also be established on a secondary basis for disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(c). Establishing service connection on a secondary basis essentially 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. 38 C.F.R. § 3.310(c). The Board finds that the Veteran has a current diagnosis of discoid lupus as reflected in the April 2019 VA treatment record. After a review of all the evidence of record, lay and medical, the Board finds that the weight of the evidence is against a finding that symptoms of lupus were chronic in service, were continuous since service, or manifested to a compensable degree within one year of service. The service treatment records are silent as to symptoms, diagnosis, or treatment of lupus during service. Post-service treatment notes reflect that the Veteran developed a rash that persisted for two or three months before he sought treatment in August 2018. An August 2018 private treatment record also documented a complaint of rash on the fact. An October 2018 private treatment record reflected that the Veteran was diagnosed with lupus. In the January 2019 NOD, the Veteran reported that that he was diagnosed with lupus after a biopsy from the rash that he developed in 2018. This evidence shows that symptoms of lupus did not manifest within one year of active service, as symptoms of lupus were not reported until 2018, nine years after service separation. See 38 C.F.R. § 4.118, Diagnostic Code 7809. In a January 2019 NOD, the Veteran stated that he mobilized to Iraq in 2008 and as part of the mobilization process, he had to undergo a medical screening process during which he received a smallpox and anthrax vaccination. The Veteran continued to receive mandatory anthrax vaccination during service. The Veteran stated that after returning home, he developed PTSD symptoms and was granted a 50 percent rating for his PTSD in 2013. The Veteran also stated that he developed a rash in March 2018 and that after he sought treatment in August 2018, he was diagnosed with lupus. The Veteran asserted with respect to environmental exposure in the war theaters today, several recent studies reported that immune pathology may be present for a decade before clinical presentation of Lupus. The Veteran also cited to an article by the Lupus Foundation of America to assert that troops sent to Iraq and Afghanistan who have PTSD are three times more likely to develop lupus and other autoimmune diseases. As to the question of direct service connection, the weight of the lay and medical evidence also supports a finding that the current lupus was not incurred in or etiologically related to service. As discussed above, service treatment records are silent as to symptoms, diagnosis, or treatment of lupus and post-service contemporaneous lay histories provided by the Veteran for the purpose of receiving treatment reflect that symptoms of lupus did not begin until seven to nine years after service separation. While post-service treatment records reflect diagnosis and treatment of the current lupus since 2018, the treatment records do not reflect evidence of a medical nexus between the current lupus and active service. In an April 2019 VA opinion, the examiner opined that the Veteran’s lupus was less likely than not caused by the claimed in-service injury, event, or illness. The examiner reasoned that the review of the medical literature did not support that lupus is due to exposure to environmental hazards and/or anthrax injections in service because lupus was not present during active duty, as the service treatment records (STRs) did not identify any treatment or skin condition consistent with diagnosis of lupus. The examiner noted that a Lupus Foundation article cited by the Veteran asserting that Veterans with PTSD are three times more likely to have lupus did not actually provide evidence to support a causal association with PTSD. The examiner also opined that the Veteran’s lupus was less likely than not proximately due to or the result of the Veteran’s service-connected PTSD. The examiner reasoned that a review of medical literal did not identify or support a causal link between discoid lupus and PTSD. In a September 2019 VA addendum opinion, the examiner opined that the Veteran’s lupus was less likely than not caused by the claimed in-service injury, event, or illness. The examiner reasoned that medical literature, to include Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016, concluded that there is insufficient and inadequate evidence to determine whether an association exists between deployment to the southwest theater of operations and skin conditions. The examiner further reasoned that evidence reflects that discoid lupus was not evident until 2018, STRs were silent for a skin condition, and the first manifestations and diagnosis of discoid lupus did not occur until many years after service. The examiner also opined that the Veteran’s lupus was less likely than not proximately due to or the result of the Veteran’s service-connected PTSD. The examiner reasoned that PTSD is not a cause of discoid lupus and that there is no medical rationale to support that PTSD as a cause of discoid lupus. The examiner also opined that the Veteran’s lupus was not caused or aggravated by the service-connected PTSD. The examiner reasoned that there was no aggravation of discoid lupus identified and that private treatment records documented adequate treatment of the discoid lupus. The examiner cited to a September 2019 treatment record documenting that the rash responded well to medication and that there was “excellent control”. Although the Board previously found the April 2019 VA opinion insufficient, the Board does find the September 2019 VA opinion to be highly probative with respect to the theories of service connection for discoid lupus as directly related to service, or as secondary to the service-connected PTSD or its treatment, and is adequately based on objective findings as shown by the record, and accordingly, the Board concludes that the medical opinion rendered was based upon a full and accurate factual premise, including the Veteran’s history, and provided a thorough and adequate rationale for the opinion given. Barr v. Nicholson, 21 Vet. App. 311 (2007); Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Therefore, the Board finds that the September 2019 VA opinion provides competent, credible, and probative evidence which shows that the Veteran’s discoid lupus is not related to service, to included claimed exposure to environmental hazards while deployed in Iraq or to the vaccinations for Anthrax, or to the service-connected PTSD. Although service in the Persian Gulf was established; the September 2019 VA examiner provided an adequate opinion that the Veteran’s discoid lupus was unrelated to such claimed exposure. The Veteran has not otherwise submitted any medical evidence that his current discoid lupus may be related to service or due to his service-connected PTSD, other than his general assertions that his lupus is related to service or secondary to service-connected PTSD. Although lay persons are competent to report symptoms of discoid lupus experienced at any time, as well as provide opinions on some medical issues, the etiology of the specific disability in this case, discoid lupus, is sufficiently complex that it falls outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Specifically, the Veteran is not shown to have the required medical knowledge or training to offer an opinion as to whether his discoid lupus is related to service or secondary to service-connected PTSD. The Board does note that the Veteran stated in his January 2019 NOD that studies indicated that Veterans who served in the Persian Gulf had a delayed onset of lupus and cited to an article noting that Veteran’s with PTSD were three times more likely to get lupus. However, the Veteran did not provide any further citation to any study supporting his claim of lupus and service in Persian Gulf. Additionally, the September 2019 examiner explained that medical literature reflected that any connection between lupus and service in the Persian Gulf was inadequate and insufficient. With regard to the assertion regarding Veterans with PTSD being more likely to have lupus, the examiner noted that the article did not assert a causal relationship between the two and that the medical literature does not support any relation between PTSD and lupus. Thus, the Veteran’s statements purporting to link the current discoid lupus to service or to service-connected PTSD are assigned no probative value. Based on the evidence of record, the weight of the competent and credible evidence demonstrates no relationship between the Veteran’s current lupus and active service. For these reasons, the Board finds that a preponderance of the evidence is against the claim for service connection for lupus on a direct, presumptive, secondary, or any other basis, and the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Mary E. Rude Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Hammad Rasul, 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.