Citation Nr: 21025496 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 14-35 823 DATE: April 28, 2021 ORDER Entitlement to service connection for a skin disability, claimed as residuals of hepatitis, is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has a skin disability began during active service, or is otherwise related to an in-service event, injury, or disease. CONCLUSION OF LAW The criteria for service connection for a skin disability, claimed as residuals of hepatitis, have not been satisfied. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1978 to March 1979. This matter comes before the Board of Veterans’ Appeals (Board) from a June 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The issue was previously before the Board in September 2020, were the Veteran’s claim was reopened and remanded for further development. The Veteran appeared at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in January 2018. A transcript of the hearing is of record. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran asserts that he has a current skin disability that is related to in-service treatment for hepatitis. The Board notes as an initial matter, that the issue has been somewhat complicated by the captions of the claim over time. The Veteran filed his first claim in March 1979 as entitlement to service connection for hepatitis. On VA examination in May 1979, the Veteran described his in-service treatment for hepatitis with blood in his urine and a skin rash. His liver function tests were normal, but he was noted to have a “few pustulous lesions” on his back. A July 1979 rating decision determined that there were no residuals of hepatitis shown on the VA examination and, as such, the claim was denied. The Veteran filed the current claim on appeal in March 2013, again for service connection for hepatitis. At the time of his April 2018 hearing before the undersigned, however, the Veteran’s representative asserted that the skin rash was part of his in-service hepatitis, with flares and scarring that has continued to the present. During the appeal, the Veteran supplemented the record with private treatment records demonstrating treatment for his skin disability. In May 2019, the Veteran filed a claim of entitlement to service connection for a skin disability, pemphigus, treated as a skin rash, with blood in his urine, during service. In June 2019 and September 2019, the Veteran underwent VA examinations for skin disabilities and hepatitis, with the examination reports noting his assertion of entitlement to service connection for a skin disability based on being treated for such during service as part of his treatment for hepatitis, and that he did not assert that he had current hepatitis or residuals of hepatitis impacting the liver or other body system. Thus, Board has recharacterized his claim as one for service connection for the current skin disability, pemphigus, specifically as related to in-service skin rashes appearing and treated coincident to his in-service treatment for hepatitis. The Appellant’s service treatment records (STRs) indicate that in December 1978, he presented with an itchy rash over the entire body for two days and was diagnosed with acute urticaria. In January 1979, he was treated for an itchy rash over eighty percent of the body for one week and was diagnosed with generalized moderate erythematous hives. His hospital discharge summary the following February 1979 indicates that he was treated for infectious hepatitis, and reported a one-month history of symptoms, in pertinent part, of mild dysuria and urticarial rash; upon discharge, he was given prescription medication to treat tinea versicolor infection of the torso. While the Veteran was discharged from his military service the following March 1979, the Board notes that this discharge was unrelated to any skin or hepatitis-related disability. Rather, a psychiatric evaluation in January 1979 noted that his “immaturity, impulsivity, and lack of motivation” made it highly unlikely that he could be helped to become a productive soldier. He was then administratively discharged under the Trainee Discharge Program while still undergoing basic training. While he was either not afforded a separation medical examination or one is not of record, he did undergo a VA medical examination after his separation in May 1979 where, as noted above, he had pustulous lesions on his back. A skin disability is not shown again by medical evidence until approximately 2009, many years after the Veteran’s service, where private dermatology records note pemphigus foliaceus diagnosed via biopsy and treated with Rituxan. The Board notes for the record that pemphigus foliaceous is an autoimmune disease that causes itchy blisters to form on the skin and Rituxan is chemotherapeutic. As noted above, the Veteran presented for VA skin and hepatitis examinations in June 2019, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. The examiner noted the Veteran’s in-service skin rashes coincident with treatment for hepatitis, and that his current diagnosis of pemphigus was in remission. The examiner opined in the negative that it was less likely than not that the Veteran’s pemphigus was related to service, explaining that his in-service urticaria (hives), often seen with acute viral hepatitis, resolved during service. The Veteran was instead currently diagnosed with an autoimmune condition, a very different disease process according to medical literature. The examiner also noted that the Veteran’s current disability causes blistering of the skin, then sloughing with sores, whereas hives or urticaria do not, and the skin stays intact. Further, any blood in the Veteran’s urine is related to irritation of the urinary tract, not the skin and mucus membranes that are affected by his pemphigus. Upon VA examination again in September 2019, the examiner noted that the Veteran’s in-service hepatitis A was a virus, a self-limiting illness that does not become chronic, and that he was treated coincident to the same for a urticarial rash, a known symptom of hepatitis A, which cleared with resolution of the hepatitis infection. The examiner also noted that his in-service hepatitis conferred him with lifelong immunity, and there was no recurrence of the condition with associated symptoms. The examiner therefore offered a negative opinion, repeating much of the June 2019 VA examiner’s opinion, discussed above. In addition, the September 2019 VA examiner also opined that the tinea versicolor infection of the torso noted in the Veteran’s in-service February 1979 hospital discharge summary was fungal, and therefore not related to his in-service hepatitis A infection, which was viral. As the Board noted in its previous remand, the above VA examiners offered adequate opinions as to whether the Veteran’s current pemphigus is related to his in-service hepatitis, urticaria, and blood in the urine, or whether his in-service tinea versicolor was related to his in-service hepatitis. However, no examiner had offered an opinion as to whether the pemphigus is related directly to his in-service tinea versicolor, with consideration of the lesions noted during the May 1979 VA examination and his lay statements of continued flares with scarring after service. Thus, the matter was remanded for an additional opinion which was first provided in September 2020 where the examiner provided the positive opinion that it was at least as likely as not that his pemphigus was incurred during his military service. Essentially, the examiner explained that, while the Veteran’s STRs are negative for pemphigus (urticaria and tinea versicolor are not characteristic of pemphigus), his post-service examination in May 1979 did note lesions consistent with pemphigus lesions. The Board notes, however, as did the RO in ordering a subsequent clarifying opinion, that the Veteran’s current pemphigus is not a disability for which service connection may be granted on a presumptive basis (i.e., manifested within one year of discharge from service). See 38 C.F.R. §§ 3.307, 3.309. As such, the Veteran’s claim is one for direct service connection, and the evidence must show that the current condition is related to symptoms/condition treated in service or an event in service. 38 C.F.R. § 3.303. The clarifying opinion was therefore provided the following October 2020, with the examiner providing the negative opinion that it was less likely than not that the Veteran’s current pemphigus is related to his in-service tinea versicolor. Again, the examiner explained that the two skin conditions referenced in the Veteran’s STRs – urticaria and tinea versicolor – are not characteristic of pemphigus foliaceus. The Board finds the above opinions, as a whole, to be highly probative as they were made by medical professionals with consideration of the specific facts in this case and after examination of the Veteran. The opinions are also supported by other evidence of record, including a lack of a diagnosis of his current skin condition until decades after service. While the Board acknowledges that the lesions on his back as early as May 1979 were noted by the September 2020 examiner as “characteristic of” pemphigus, no definitive diagnosis was provided at the time of the earlier examination. Moreover, there is no medical opinion or competent and credible evidence in significant conflict with the VA medical opinions. While an April 2019 statement provided by the Veteran’s private dermatologist discusses his history of treatment, it contains no etiological opinion. The Board has considered the Veteran’s statements, to include his assertions that his current skin disability is related to service. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., skin lesions; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, his lay assertions do not constitute evidence upon which service connection can be granted. To the extent the Veteran asserts a continuity of symptomatology beginning during service, the Board finds these statements to lack credibility as they are in direct conflict with his medical treatment records which are absent his currents kin disability until decades after service. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. For the above reasons, the preponderance of the evidence is against the claim and service connection is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Scarduzio, 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.