Citation Nr: 21025890 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-39 262 DATE: April 29, 2021 REMAND Entitlement to service connection for skin disability, to include seborrheic dermatitis and psoriasis, as due to herbicide exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1969 to April 1971. The Veteran has service in the Republic of Vietnam from March 1970 to April 1971. His exposure to herbicide agents is presumed. 38 C.F.R. § 3.307(a)(6)(iii). This appeal comes before the Board of Veterans’ Appeals (Board) from a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the claims file. See Hearing Transcript (September 2019). The Board remanded the issue in December 2019 and in November 2020. See BVA Decision (December 2019); see also BVA Decision (November 2020). Most recently, the Board remanded for etiology opinion regarding the Veteran’s claimed skin disability. The Board finds that there has not been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for skin disability to include as due to herbicide exposure. The Veteran seeks service connection for his skin disabilities and has asserted that they are related to his in-service skin complaints; or alternatively, due to herbicide exposure in the Republic of Vietnam. He believes he has developed a skin cancer condition due to service. See NOD (January 2014); see also Form 9 (July 2016). The Veteran testified that he had a number of skin encounters in service, noting he had poison oak in 1970, which was treated and cleared up, but that he developed skin issues later assessed as acne rosacea. The Veteran also reported that he has been diagnosed with psoriasis, which he believed actually “was just starting” in service. See Hearing Testimony at 13. He acknowledged that Swedish American, a medical facility in Rockford, Illinois, no longer had records of his care. Compensation may be awarded for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131. Service connection basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). Certain diseases are presumptively associated with exposure to herbicide agents for those who served in the Republic of Vietnam during the Vietnam War Era. The Veteran has not been shown to have a skin disease that is included in the list of diseases presumptively associated with herbicide agent exposure. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). Notwithstanding, service connection may be established with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (providing that the provisions set forth in Combee are equally applicable in cases involving claimed Agent Orange exposure). The Board concludes that, remand is necessary to ensure that VA has met its duty to assist. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The Veteran’s service treatment records (STRs) show that, in April 1971, he was treated for tinea capitis with Selsun shampoo, and later, in April 1971, prescribed a scalp ointment and Griseofulvin (antibiotic) tablets to take daily for 28 days (past his discharge from active service). A December 1970 STR reflects that the Veteran had an abscess on his right temple that had swollen to the size of a ping pong ball with purulent discharge; subsequently, a skin culture showed coagulase positive staph aureus. The Veteran’s April 1971 Report of Medical Examination at separation revealed normal clinical evaluation of the skin. VA received, in May 1971, the Veteran’s original VA disability claim. However, it did not include any skin disorder claim. See VA Form 21-526 (May 1971). In 2012, VA received the Veteran’s claim for acne rosacea of the face and elbows, which he reported had begun in June 1971. A skin disorder is first documented post service in VA treatment records dated in May 2012. A May 2012 VA treatment note reflects that the Veteran presented for his annual exam and that he “has a skin condition which he states is related to AO on his elbows.” Objectively, the skin was warm and dry; there was erythematous macules covered with silvery scale on extensor surface of forearms. The diagnosis was psoriasis, and he was prescribed clobetasol cream. See CAPRI at 14-16 (July 2013). VA treatment records obtained in July 2013 include rosacea on the Veteran’s problem list. An August 2013 VA treatment note reflect that the Veteran was prescribed Ketoconazole shampoo for seborrheic dermatitis affecting the scalp and Ketoconazole cream for seborrheic dermatitis affecting the central face. See CAPRI (May 2016). A July 2013 VA skin examination reflects a diagnosis of psoriasis (1998) and rosacea (1971). See C&P Exam (July 2013). By history, he had rosacea since 1971 with worsening over the last five years and that, since 1998, he had eruptions of the elbows and legs without seasonal variation. Treatment included topical treatment without systemic therapy. Also, examination disclosed mild erythema of the face and telangiectasiae of the cheeks and nose, along with mild scaling and erythema of the eyebrows, nasal labial grooves, and ears; this was assessed to be seborrheic dermatitis. An October 2019 VA dermatology note reflects history of psoriasis for years, treated last with triamcinolone. Psoriasis involved the left thigh and elbows bilaterally; there was also mild seborrheic dermatitis on face and ears, and rosacea of the cheeks. Past history included actinic keratosis. The diagnoses were psoriasis, seborrheic dermatitis and rosacea. A February 2020 VA skin examination reflects diagnoses for seborrheic dermatitis and psoriasis. See C&P Exam (February 2020). Psoriasis was located on the left anterior thigh, elbows, legs, and behind the knees. Seborrheic dermatitis was located on the face and both ears. The skin conditions were considered stable and under recurrent UV light therapy. Resolved skin disabilities were noted as actinic keratosis, tinea capitus, and poison oak. A February 2020 VA medical opinion opined that the Veteran’s skin disabilities are not at least as likely as not related to an in-service injury, event, or disease. See C&P Exam (February 2020). Regarding cancer, the examiner confirmed the Veteran did not present with any skin cancer disability at any time. Id. The rationale noted the Veteran was diagnosed with actinic keratosis facial lesions in 2013. These were treated with one application of liquid nitrogen and resolved. Regarding poison oak, the examiner noted that the Veteran was treated with steroid and noted that the course of treatment was acute with complete resolution. Regarding tinea capitus, the examiner noted that it resolved with treatment (Selsun shampoo) in April 1971. There examiner noted there is no evidence of chronicity of care. A December 2020 addendum opinion from a medical doctor, general practice and obstetrics and gynecology, concluded that it was less likely than not that (any of) the Veteran’s skin disability is incurred in or caused by the claimed in-service injury, event, or disease. See C&P Exam (December 2020). The opinion reflects diagnoses for psoriasis, seborrheic and resolved actinic keratoses. It also indicated that other skin condition noted in service had resolved. For example, although the Veteran was treated for a skin abscess secondary to an apparent insect/spider bite, with resultant staph aureus infection, it was ultimately treated and resolved with erythromycin in December 1970 and bears no relationship whatsoever to the Veteran’s co-morbid skin conditions. Similarly, although the Veteran was treated for tinea capitus with Selsun Blue shampoo (selenium) in April 1971 in service, it resolved in service and it is not the fungus typically associated with seborrheic skin conditions. The opinion acknowledged that there had been in service fungal treatment (oral antifungal, griseofulvin) that resolved the condition; and that a December 1970 STR reflects that a single treatment for poison oak with IM Depo-Medrol (steroid) resolved the condition. The December 2020 VA addendum opinion reflects that there was no chronic skin disability at separation in April 1971, noting that positive skin findings would likely not have been missed due to the nature of the physical examination, and that the Veteran had not required or obtained care for any condition decades later, which suggested no continuity of symptomatology of any skin disability following separation. As to actinic keratoses, it was noted that these are precancerous lesions believed to be due to chronic sun exposure, with associated skin damage, and that such are not related to service or Agent Orange exposure. However, regarding seborrheic dermatitis, the December 2020 VA addendum opinion noted that the Veteran has been diagnosed with seborrheic dermatitis (face and scalp) and psoriasis (involving multiple joints, trunk, and thighs), but that these conditions are considered to be mediated by the immune system. The opinion concluded that seborrheic dermatitis and psoriasis were less likely than not related to service to include herbicide agent exposure because they were not shown in service or until 30 years post service. He explained that, as to herbicides, the current widely accepted peer-reviewed literature did not support a link between the conditions and herbicide agent exposure. He added that an exposure causing a skin condition would be anticipated to manifest at the time of such exposure or proximate to it, and not three decades later. The Board finds that the December 2020 VA addendum opinion, as it pertains to the diagnoses of seborrheic dermatitis (face and scalp) and psoriasis (involving multiple joints, trunk, and thighs), is inadequate for adjudicative purposes. First, while it notes that the Veteran’s in-service skin findings and treatment, it does explain why these skin symptoms do not comport with early manifestations of decades later diagnosed seborrheic dermatitis and psoriasis as theorized by the Veteran. Second, it appears to rely heavily on the absence of findings at service separation and the many years of no documented treatment without considering the Veteran’s reports of onset of symptoms. Notably, an absence of “chronicity of care” is not a valid basis for a negative medical conclusion given that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service. Cosman v. Principi, 3 Vet. App. 503 (1992); see also 38 C.F.R. § 3.303(d). Third, the December 2020 VA addendum opinion references the absence of general medical literature supporting nexus without discussing the facts specific to the Veteran vis-à-vis the medical literature that was reviewed. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (stating that a medical rationale based solely on general medical literature without discussing the specific facts pertaining to a veteran’s condition or individual circumstances is inadequate). Given the above, the Board finds that remand is necessary to obtain another medical opinion in this appeal. See Barr v. Nicholson, 21Vet. App.303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. The matter is REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from August 2020 to the Present. 2. Obtain an addendum opinion from a dermatologist clinician regarding the etiology of the Veteran’s diagnosed (1) seborrheic dermatitis and (2) psoriasis. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with (1) seborrheic dermatitis and (2) psoriasis. If there is any medical reason to accept or reject the proposition that the Veteran’s reported symptoms in service and thereafter represented the onset of his currently diagnosed seborrheic dermatis and/or psoriasis, this should be noted. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. The clinician must opine on: (a) Whether the Veteran’s diagnosed seborrheic dermatitis at least as likely as not (1) began during active service or (2) is related to an in-service injury, event, or disease, to include herbicide agent exposure. Consider and expressly address (A) the Veteran’s in-service findings and treatment for tinea capitis to include whether this condition represents the onset of later diagnosed seborrheic dermatitis; (B) whether seborrheic dermatitis is proximately due to in-service findings for staph aureus. Explain. (b) Whether the Veteran’s diagnosed psoriasis at least as likely as not (1) began during active service or (2) is related to an in-service injury, event, or disease, to include herbicide agent exposure. Consider and expressly address the Veteran’s in-service findings and treatment for tinea capitis to include whether this condition represents the onset of later diagnosed seborrheic dermatitis. Explain. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): An adequate medical opinion may not be predicated solely on the absence of literature supporting nexus without discussing those facts specific to this Veteran. 3. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. A. Macek, 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.