Citation Nr: 21025676 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 14-36 403 DATE: April 28, 2021 ISSUE Entitlement to service connection for a skin rash due to an undiagnosed illness. ORDER Entitlement to service connection for a skin rash due to an undiagnosed illness is denied. FINDINGS OF FACT 1. The Veteran’s skin rash has a known clinical diagnosis of sebaceous hyperplasia and is not shown to be a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness attributable to service in Southwest Asia. 2. A skin rash was not manifest during active service, or until many years after service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for a skin rash due to an undiagnosed illness have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5103A; 38 C.F.R. §§ 3.303, 3.304, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the United States Army from August 1989 to November 1991. The Veteran's DD Form 214 confirms service in Southwest Asia from September 1990 to April 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Board notes that jurisdiction of this matter now lies with the RO in St. Petersburg, Florida. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at an April 2018 Board video conference hearing. A transcript of that hearing has been associated with the claims file. The Board remanded this issue in June 2018, November 2019 and July 2020 for further development. Upon review of the Veteran’s claim file, the Board finds that there has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Therefore, the Board will proceed to the merits of the issue on appeal. Service Connection Generally, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). Under 38 C.F.R. § 3.317, there are two types of qualifying chronic disabilities: (1) An undiagnosed illness; and (2) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome, (2) fibromyalgia, and (3) functional gastrointestinal disorders. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 3, 9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. 38 C.F.R. § 3.317 (a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). "Objective indications of chronic disability" include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuro-psychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(4). Notwithstanding the foregoing presumptive provisions, the Veteran is not precluded from establishing service connection for a disease averred to be related to Gulf War service, as long as there is proof of such direct causation. See generally Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. In this case, the Board has reviewed all of the evidence of record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, with regard to the Veteran's claims. Entitlement to service connection for a skin rash due to an undiagnosed illness. The Veteran is claiming service connection for a skin rash which he contends is the result of his exposure to environmental factors during his service in Southwest Asia. The Veteran's service treatment records are silent for any complaints, treatment or diagnosis of a skin disorder. The Veteran’s August 1991 separation examination is negative for any complaints of skin problems. The Veteran’s VA treatment records reflect that he has made complaints about skin problems over the course of the appeal period. The Veteran was afforded a VA general medical examination in October 2010. At that time the Veteran reported developing a rash on and around his nose 10 years prior that would bleed when he shaved. Upon examination, tiny pinhead type lesions were noted on the Veteran's forehead in-between his eyebrows and around his nose. Non-specific rash was diagnosed, and it was noted that dermatology may need to diagnose the condition. The Veteran was afforded another VA general medical examination in May 2011. The Veteran again reported that his rash developed 10 to 12 years prior around his nose that bleeds when he shaves and has gotten progressively worse. Upon examination, small, papular lesions on the forehead, scalp, and cheek in the nasolabial fold were noted. A non-specific skin rash was diagnosed; however, it was noted that a dermatology examination is indicated but had not been requested. During the April 2018 Board hearing the Veteran testified to his different types of chemical exposures when he was in the Persian Gulf. Specifically, he testified that he would hear chemical alarms go off and he knew munitions were being blown up around him. He testified that he would drive through burning oil fields and he would also have to take drums of jet fuel and pour them into the oil fields. The Veteran further testified that he has never been seen by a dermatologist for his skin condition. In a June 2018 decision, the Board found that the Veteran had not received an adequate VA examination as both the October 2010 and May 2011 VA examiners indicated that the Veteran should be diagnosed by a dermatologist, and an examination with a dermatologist had not been conducted. At that time the Board remanded with instructions that the Veteran be afforded a new VA examination with a dermatologist. In October 2018 the Veteran was afforded the Board-directed VA examination. At that time the examiner noted that the Veteran had four raised white papules on his face which were approximately one millimeter each in size. The October 2018 VA examiner, however, was a nurse practitioner, not a dermatologist as the June 2018 Board remand directives explicitly required. Therefore, in November 2019 the matter was again remanded for the Veteran to be afforded a new VA examination with a dermatologist. The Veteran was afforded a VA examination in January 2020. The examiner observed skin papules on the Veteran’s face and noted that this condition interfered with his ability to shave his face. At that time the examiner opined against a nexus between the Veteran’s skin condition and his active duty service. However, there is no indication in the claims file that the January 2020 examiner was a dermatologist, as was required by the Board directives. Therefore, the matter was again remanded in July 2020 for the Veteran to be afforded a new VA examination. Most recently, a VA examination was conducted in February 2021. The examining physician was a dermatologist and he noted that he reviewed the Veteran’s claim file and conducted an in-person examination of the Veteran. The Veteran reported that he has noticed two more growths on his face over the past few years and they occasionally bleed when he is shaving. The examiner observed the Veteran to have three yellowish-colored hyperplastic papules with central umbilication on his forehead and cheeks. The examiner diagnosed sebaceous hyperplasia with an onset date of 20 years prior. The examiner opined that it was less likely than not that the Veteran’s skin condition was related to service. In providing a rationale the examiner explained that the Veteran’s sebaceous hyperplasia was unrelated to an exposure to any environmental factors or chemicals. The examiner explained that this disease is genetic and benign in nature. The Board finds the February 2021 VA opinion to be of great probative value. Indeed, the examiner considered the Veteran's contention, the claims file, and clinical medical evidence before providing a negative opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiner's negative opinion was supported by a sufficiently clear and well-reasoned medical rationale and was consistent with the verifiable facts regarding the Veteran's contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). Notably, the examiner explained that the Veteran’s sebaceous hyperplasia was genetic in nature and was unrelated to an exposure to any environmental factors or chemicals. There is no evidence that the February 2021 VA examiner was not competent or credible, and as the report was based on accurate facts and objective examinations, the Board finds that it is entitled to significant probative weight as to the etiology of the Veteran's. sebaceous hyperplasia. See Nieves-Rodriguez, Id. The Board recognizes that the Veteran has contended that his skin rash is due to environmental exposures while serving in the Persian Gulf and therefore he has essentially argued that service connection is warranted for a skin rash under 38 C.F.R. § 3.317. However, the Veteran has a distinct diagnosis of sebaceous hyperplasia based on the opinion of the February 2021 VA examiner and the diagnosis was explained and included conclusive etiology or pathophysiology. Because the Veteran has a distinct medical diagnosis of sebaceous hyperplasia, his claimed skin rash is not an undiagnosed illness or a medically unexplained chronic multisymptom illness. Accordingly, service connection under 38 C.F.R. § 3.317 is not warranted. See 38 C.F.R. § 3.317 (providing that service connection is warranted under this section for a qualifying chronic disability, which means a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness). The Board acknowledges that the Veteran is competent to provide statements as to his beliefs that his skin rash is related to service. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). In order for lay evidence to be competent, the individual must have personal knowledge, derived from his/her own senses, of what is being attested; "[c]ompetent testimony is thus limited to that which the witness has actually observed, and is within the realm of his personal knowledge." Layno v. Brown, 6 Vet. App. 465, 471 (1994). Here, the Veteran is competent to provide statements about his symptoms relating to his claimed skin rash. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical opinion regarding etiology of such a condition of any kind. See 38 C.F.R. § 3.159 (a)(1) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what he has experienced, he is not competent to ascertain the etiology of any current condition, as the causative factors for such are not readily subject to lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, his assertions to that effect are of no probative value. In addition, the Board finds that the gap in time between the Veteran's last date of active service, in November 1991, to his initial evaluation by any medical provider regarding his skin rash in October 2010 to be probative of a lack of nexus between the diagnosed current disability and active service. A negative inference may be drawn from the absence of complaints or treatment for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). There are no competent medical opinions of probative value in favor of a positive nexus to active service from any VA examiner or medical treatment provider from any source. Upon review of the record, the Board concludes that entitlement to service connection for a skin rash is not warranted. The Board notes a current diagnosis of sebaceous hyperplasia and thus the requirement for a current disability is shown. The Board acknowledges the Veteran's contentions, and the Veteran's post-service statements are noted. However, the record is silent for mention of skin problems until the Veteran’s October 2010 VA examination, and there is no competent evidence to tie the current assertion to any in-service disease or injury. The Board thus finds the Veteran fails the third prong of the test for entitlement to service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. In summary, the medical evidence in this case outweighs the Veteran's assertions that his current sebaceous hyperplasia is of service origin. For these reasons, the preponderance of the evidence is against the claim and service connection for a skin rash is not warranted. As the preponderance of the evidence weighs against the claim, the benefit of the doubt rule is not for application. 38 U.S.C. § 5107(b), 38 C.F.R. § 4.3; see Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Nettey, 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.