Citation Nr: 21026754 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 14-11 398 DATE: May 3, 2021 REMANDED Entitlement to service connection for a skin disability is remanded. REASONS FOR REMAND The Veteran had active duty service from November 1967 to June 1969. He has confirmed service in the Republic of Vietnam, and among other awards he is in receipt of the Bronze Star with Oak Leaf Cluster. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), in which the RO, in relevant part, denied service connection for a skin disability. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a videoconference hearing in February 2016. A copy of the hearing transcript has been reviewed and associated with the claims file. This matter was previously before the Board in April 2018 and September 2020, and it was remanded each time for further evidentiary development. Entitlement to service connection for a skin disability is remanded. Throughout the rating period on appeal, the Veteran has been diagnosed with squamous cell carcinoma, actinic keratosis, seborrheic keratosis, markedly atypical compound nevus, seborrheic dermatitis, and erythrotelangiectatic rosacea. He asserts that these skin disabilities were incurred in, or otherwise caused by, his active duty service, including due to his conceded exposure to herbicide agents and due to sun exposure. The Veteran underwent a VA examination in November 2019, in which the examiner opined that his skin disabilities are less likely than not caused by his service. In the Board's September 2020 remand, it found the November 2019 VA examination and medical opinion inadequate because they did not discuss the Veteran's hearing testimony that he noticed spots on his skin soon after separation from service and sought skin treatment in the 1970s. The examiner opined that his skin disabilities are not presumptively related to exposure to herbicide agents, but he did not discuss herbicide agent exposure on a direct basis or consider the Veteran's in-service sun exposure as a cause of his skin disabilities. The examiner also noted the Veteran's relatively fair skin, which seemed to weigh in favor of him having excessive sun exposure in service, and the Board requested clarification on that statement. A new VA opinion was issued in November 2020, in which the examiner opined that the Veteran's diagnosed squamous cell carcinoma and actinic keratosis are less likely than not related to his service. The examiner considered herbicide agent exposure as a direct cause of his squamous cell carcinoma and actinic keratosis and concluded that no medical evidence supports such a causal connection. The examiner also stated that, while squamous cell carcinoma and actinic keratosis are known to be caused by exposure to ultraviolet rays, it is less likely than not that sun exposure during his service of less than two years caused his current diagnoses. He stated that actinic keratosis and squamous cell carcinoma "occur[] when [they are] diagnosed," and one cannot presume that the spots the Veteran noticed on his skin in the 1970s are the same conditions he was diagnosed with more than 35 years later, especially given the fact that the Veteran had no training in diagnosing skin disorders. The Board finds that the November 2020 examination complied with the Board's September 2020 remand instructions. However, an addendum opinion is warranted because the Veteran has since received new skin diagnoses that were not contemplated by the examiner. Specifically, he was diagnosed with seborrheic dermatitis and erythrotelangiectatic rosacea on his face and seborrheic keratosis on the right flank in February 2020, and a September 2020 biopsy resulted in a diagnosis of markedly atypical compound nevus on the right flank. Accordingly, an addendum opinion is necessary to consider the nature and etiology of these diagnoses. The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file the Veteran's updated VA treatment records, from October 2020 to the present. 2. Obtain and associate with the claims file the VistA images associated with the Veteran's VA treatment records, including the total dermatopathology images of the right lateral flank, skin pigmented melanocytic lesion referenced in the September 2020 pathology report. 3. After completion of #1 and #2, obtain an addendum opinion from the November 2020 VA examiner or, if he is unavailable, then another similarly qualified examiner may respond instead. The claims folder, including a copy of this remand, must be made available to the examiner and such review should be noted in the examination report. A VA examination is only necessary if deemed so by the examiner. The examiner should provide an opinion as to the following: (a.) Based on a review of the Veteran's pertinent history and examination results, is it at least as likely as not (a 50 percent or greater degree of probability) that his diagnosed seborrheic keratosis is related to an in-service event, injury, or illness, to include the Veteran's conceded in-service exposure to sun and/or to herbicide agents? (b.) Based on a review of the Veteran's pertinent history and examination results, is it at least as likely as not (a 50 percent or greater degree of probability) that his diagnosed seborrheic dermatitis is related to an in-service event, injury, or illness, to include the Veteran's conceded in-service exposure to sun and/or to herbicide agents? (c.) Based on a review of the Veteran's pertinent history and examination results, is it at least as likely as not (a 50 percent or greater degree of probability) that his diagnosed erythrotelangiectatic rosacea is related to an in-service event, injury, or illness, to include the Veteran's conceded in-service exposure to sun and/or to herbicide agents? (d.) Based on a review of the Veteran's pertinent history and examination results, is it at least as likely as not (a 50 percent or greater degree of probability) that his diagnosed markedly atypical compound nevus on the right flank is related to an in-service event, injury, or illness, to include the Veteran's conceded in-service exposure to sun and/or to herbicide agents? In rendering the requested opinions, the examiner must note that service connection may be established for a disability shown to be due to exposure to herbicide agents, irrespective of whether the condition is considered a condition subject to presumptive service connection due to exposure to an herbicide agent. The examiner must provide a comprehensive rationale for each proffered opinion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Pratt 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.