Citation Nr: 21027112 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 15-41 047A DATE: May 4, 2021 ORDER Entitlement to an initial disability rating higher than 10 percent prior to May 21, 2015, and a rating higher than 20 percent from May 21, 2015, to June 16, 2018, for the service-connected chronic lumbosacral strain with levoscoliosis of T2 to T4, anterior compression of T4, minimal spondylosis of T4 to T7 and L1 to L4, degenerative disc disease of L4-5, sacralization of L5, and intervertebral disc syndrome (hereinafter chronic lumbosacral strain disability), is denied. A 40 percent rating, but not higher, as of June 17, 2018, for the service-connected chronic lumbosacral strain disability is granted. Entitlement to an initial compensable rating prior to January 25, 2018, for the service-connected psoriasis is denied. A 10 percent rating, but not higher, as of January 25, 2018, for the service-connected psoriasis, is granted. REMANDED Entitlement to an initial disability rating higher than 30 percent prior to May 21, 2018, and a rating higher than 70 percent on and thereafter, for posttraumatic stress disorder (PTSD) with a recurrent major depressive disorder (MDD) and a persistent depressive disorder, is remanded. FINDINGS OF FACT 1. Prior to May 21, 2015, range of motion testing of the Veteran's thoracolumbar spine did not show forward flexion functionally limited to 60 degrees or less, or a combined range of motion less than 120 degrees, and pain or spasm did not result in functional loss, abnormal gait, or abnormal spinal contour; and from May 21, 2015, to June 16, 2018, range of motion testing for the Veteran's thoracolumbar spine did not show forward flexion functionally limited to 30 degrees or less. 2. As of June 17, 2018, the Veteran's forward flexion was shown to be functionally limited to 30 degrees, but at no point during the period on appeal, was he shown to have ankylosis, range of motion so limited such as to be functionally equivalent to ankylosis, or incapacitating episodes of intervertebral disc syndrome. 3. Prior to January 25, 2018, the Veteran's psoriasis did not affect more than five percent of entire body or of exposed areas. 4. As of January 25, 2018, the Veteran's psoriasis was assessed as affecting between five and less than 20 percent of the Veteran's total body area and exposed areas, but at no point during the period on appeal did psoriasis require systemic therapy such as corticosteroids or other immunosuppressive drugs, or therapy such as, but not limited to phototherapy, retinoids, biologics, photochemotherapy, or psoralen with long-wave ultraviolet-A light (PUVA). CONCLUSIONS OF LAW 1. The criteria for an initial disability rating higher than 10 percent prior to May 21, 2015; or for a rating higher than 20 percent from May 21, 2015, to June 16, 2018, for service-connected chronic lumbosacral strain disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5237, 5243. 2. The criteria for a 40 percent rating, but no higher, as of June 17, 2018, for service-connected chronic lumbosacral strain disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DCs 5237, 5243. 3. The criteria for an initial, compensable disability rating for service-connected psoriasis, for the period prior to January 25, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, DC 7806 (2017 & 2019). 4. The criteria for a 10 percent rating for psoriasis, but no higher, for the period as of January 25, 2018, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, DC 7806 (2017 & 2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had multiple periods of active duty service between February 1981 and January 2012. This current appeal before the Board of Veterans' Appeals (Board) arose from an October 2013 rating action in which a Department of Veterans Affairs (VA) Regional Office (RO) granted service connection for adjustment disorder with mixed disturbance of anxious and depressed mood, for the chronic lumbosacral strain disability, and for psoriasis, assigning 30 percent, 10 percent and noncompensable ratings, respectively, effective January 17, 2012. During the pendency of the Veteran's appeal, in a November 2015 rating decision, the RO increased the disability rating for the lumbosacral strain disability to 20 percent, effective May 21, 2015. In an August 2018 rating decision, the RO recharacterized the service-connected psychiatric disability as PTSD with MDD, recurrent and persistent depressive disorder, and increased the disability rating for the disability to 70 percent, effective May 21, 2018. The Board remanded the current claims on appeal to the Agency of Original Jurisdiction (AOJ) for further development in May 2019 and December 2020. The Board additionally disposed of service connection claims for respiratory and eye conditions in the December 2020 decision. Increased Ratings At the outset, the Board is satisfied that all notification and development actions needed to fairly adjudicate the higher rating claims herein decided have been accomplished, to the extent possible. The Veteran has been notified of what is needed to substantiate the claims, and relevant VA examination reports and VA treatment records have been associated with the claims file. These reports also document his lay statements regarding the higher rating claims decided herein. Notably, the AOJ complied with the Board's December 2020 remand insofar as arranging for to Veteran to undergo new VA examinations, as directed. The Board notes, however, that, because the Veteran declined to report to new VA examinations in February 2021, scheduled in connection with these decided claims, there is no recourse but for the Board to decide the claims based on the evidence of record. 38 C.F.R. § 3.655(a). There is no identified evidence for which the Veteran has provided appropriate authorization to obtain, or other existing, relevant evidence outstanding with respect to these claims, and he has not alleged any error or omission in the assistance provided. Hence, he is not prejudiced by the Board proceeding to a decision on these claims at this juncture. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to a claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If the preponderance of the evidence weighs against the claim, it is denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Board will consider entitlement to staged ratings to compensate for times since filing of a claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Chronic Lumbosacral Strain An initial rating of 10 percent is in effect prior to May 21, 2015, and a 20 percent rating is in effect as of that date, for the Veteran's for chronic lumbosacral strain disability, pursuant to the General Rating Formula for Diseases and Injuries of the Spine under 38 C.F.R. § 4.71a. Although the assigned Diagnostic Code for the Veteran's lumbosacral spine disability was DC 4243, for IVDS, the Board observes that Veteran has not been shown to have the required incapacitating episodes of IVDS such as to warrant a rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Nor has he been shown to have disc herniation with compression and/or irritation of the adjacent nerve root such as to warrant a rating under this Diagnostic Code pursuant to recently amended regulations for evaluating musculoskeletal disabilities that went into effect on February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5253). Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion (ROM) of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a. A 20 percent rating is assigned where there is forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees, or the combined ROM of the thoracolumbar spine is not greater than 120 degrees, or there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent rating is assigned where there is forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is assigned where there is unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent rating is assigned where there is unfavorable ankylosis of the entire spine. Id. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, may not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on § 4.71a criteria."). In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that whenever possible, VA examiners record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Notably, while range of motion testing in passive versus active motion, and in non-weight bearing was not properly reported for the Veteran, in accordance with Correia, and while a complete description of his reported flare-ups was not provided in accordance with Sharp, the Board again notes that the Veteran declined to be seen for new VA examination in February 2021, which was requested to describe the current severity of his lumbosacral spine disability, including findings pertaining to flare-ups and ranges of motion. Thus, the Board is without recourse to obtain examination findings fully compliant with Correia and Sharp, but rather, is forced to rate the disability on the evidence of record. Turning to the evidence of record, during initial VA-contracted examination of the thoracolumbar spine in August 2013, the Veteran reported flare-ups of disability manifested by limitations of activities such as prolonged sitting, standing, walking, repetitive bending, and heavy lifting, as a result of pain. Range of motion testing revealed full flexion to 90 degrees, with objective evidence of pain beginning at 75 degrees. Extension was limited to 30 degrees, with objective evidence of pain beginning at 15 degrees. Right and left lateral flexion and right and left lateral rotation were all normal at 30 degrees, but these motions exhibited objective evidence of pain beginning at 15 degrees. After three repetitions of repetitive motion, flexion was limited to 75 degrees, and extension and right and left lateral flexion and right and left lateral rotation were all limited to 15 degrees. The examiner noted that the Veteran had functional loss, functional impairment, and/or additional limitation of ROM on repetitive use as a result of pain on movement and interference with sitting, standing, and/or weight bearing. While the Veteran had localized tenderness or pain to palpation for the thoracolumbar spine joint and/or soft tissue, he did not have guarding or muscle spasm. During VA-contracted examination in May 2015, the Veteran reported having flare ups with pushing, and prolonged sitting and standing. The examiner noted that the Veteran had normal ROM on testing for all thoracolumbar spine motions. Repetitive motion testing revealed flexion limited to 85 degrees, and extension and right and left lateral flexion and right and left lateral rotation all limited to 25 degrees. The examiner noted that the Veteran had pain on active, passive, or repetitive motion that contributed to functional loss or additional ROM limitation. The examiner assessed that pain during flare-ups resulted in an additional five degrees ROM loss in all ROMs. The examiner also noted that the Veteran had guarding of the thoracolumbar spine that result in abnormal spinal contour. Such findings were noted in all subsequent examination reports, except for an April 2018 VA examination, of the Veteran's thoracolumbar spine. The Veteran gave a substantially similar report with respect to flare-ups of his thoracolumbar spine disability during VA-contracted examination in August 2017. Range of motion testing revealed flexion to be limited to 70 degrees, and extension and right and left lateral flexion and right and left lateral rotation all limited to 20 degrees. ROM testing revealed the same results after three repetitions. The examiner also opined that the Veteran would have the same ROM results after repetitive use over a period of time and during flare-ups of joint disability. The examiner indicated that ROM testing for pain on passive ROM and in non-weight bearing could not be performed or was medically inappropriate, but did not provide reasons why. At a VA-contracted examination in December 2017, the Veteran described flare ups as consisting of pain that limited standing and bending. Range of motion testing revealed flexion to be limited to 50 degrees, extension limited to five degrees, and right and left lateral flexion and rotation all limited to 10 degrees. The Veteran had pain during all ROMs, however, the point where pain began was not noted. The examiner indicated that ROM testing for pain on passive ROM and in non-weight bearing could not be performed or was medically inappropriate, however, the examiner again did not provide reasons why. The examiner also assessed that the Veteran's ROM loss during flare-ups or with repeated use over a period of time could not be determined without resorting to mere speculation since the Veteran was not examined during repeated use over a period of time, or during a flare-up of disability. An April 2018 VA examination report described the Veteran's flare-ups of the spine disability as consisting of a stabbing type of pain, like having two knives in his back. He reported having limited use of the back for daily activities, such as doing chores around the house and driving. ROM testing revealed flexion to be limited to 60 degrees, extension limited to five degrees, and right and left lateral flexion and rotation all limited to 10 degrees. The examiner assessed that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time or during flare-ups. The Veteran was most recently afforded a VA-contracted examination of his thoracolumbar spine in June 2018. The Veteran described having flare-ups of the back throughout the day and night, which limited his daily activities. ROM testing revealed flexion to be limited to 30 degrees, and extension, and right and left lateral flexion and rotation were all limited to 10 degrees. The examiner noted pain that caused functional loss on all ROMs but did not indicate the points where pain began. While the examiner assessed that pain caused additional functional loss during flare-ups and repeated use over a period of time, the examiner also indicated that the degree of additional limitation/ROM loss could not be provided because the flare-ups varied with the activity performed. Given the above, the Board cannot make a finding that the Veteran is entitled to a disability rating higher than 10 percent prior to May 21, 2015, or a disability rating higher than 20 percent from May 21, 2015, to June 16, 2018. In this regard, prior to the May 2015 VA examination, the Veteran's lumbosacral strain disability more closely approximated the criteria for a 10 percent evaluation, where the August 2013 examination findings noted full flexion to 90 degrees, and combined ROM findings of no less than 225 degrees. Even taking into account the point where ROM was limited as a result of repetitive motion, the combined ROM was still no less than 150 degrees, still within the criteria for a 10 percent disability rating. Moreover, the Veteran was not found, and did not otherwise report, guarding or muscle spasms. Similarly, from May 21, 2015, to June 16, 2018, while the Veteran's thoracolumbar spine examination reports indicated that he did have guarding and muscle spasms that resulted in abnormal spine contour, and had a combined range of motion less than 120 degrees as of the time of the December 2017 VA examination, he was at no point during that portion of the appeal period found to have forward flexion of the thoracolumbar spine limited to 30 degrees or less. At most, he was noted to have flexion limited to 50 degrees at the time of the December 2017 VA-contracted examination, and there was no additional finding that flare-ups or repeated use over a period of time further limited his ROM. As such, the preponderance of the evidence is against the Veteran's claim for a rating higher than 10 percent prior to May 21, 2015, or a disability rating higher than 20 percent from May 21, 2015, to June 17, 2018. Notably, as of the time of the June 2018 VA-contracted examination, the Veteran was found to have forward flexion limited to 30 degrees, consistent with the criteria for a 40 percent disability rating for the lumbosacral strain disability. At no point, however, has the Veteran been shown to have ankylosis, or range of motion so limited such as to be functionally equivalent to ankylosis, in order to warrant the assignment of a higher disability rating. Accordingly, the Board finds that from June 17, 2018, the Veteran's service-connected lumbosacral spine disability more closely approximated a 40 percent rating, but no higher, due to forward flexion limited to 30 degrees. In reaching the foregoing decisions, the Board has considered the Veteran's assertions as to his limitations in performing physical work of any kind, and difficulty getting out of bed due to back pain. To the extent, however, that he believes that he is entitled to a higher rating than that which is assigned herein, the Board concludes that the findings during medical evaluations are more probative than are his lay statements, especially with respect to his specific lumbosacral spine ROMs. As such, in reaching the conclusion that a disability rating of 40 percent, but no higher, is warranted as of June 19, 2018, for the service-connected lumbosacral spine disability, the Board has considered the assertions of the Veteran, but has also relied heavily on VA, and VA-contracted examination reports, which duly considered his subjective symptoms but did not show limitation of function approximating the criteria for the next higher rating. Psoriasis The Veteran is currently assigned a noncompensable rating for service-connected psoriasis pursuant to the criteria found at 38 C.F.R. § 4.118, DC 7816. Effective August 13, 2018, during the course of the Veteran's appeal, the criteria for rating skin/scar disabilities were revised. See 83 Fed. Reg. 32592 (July 13, 2018); 83 Fed. Reg. 38663 (Aug. 7, 2018). The Secretary has determined that "claims pending prior to [August 13, 2018] will be considered under both old and new rating criteria, and whatever criteria is more favorable to a veteran will be applied." 83 Fed. Reg. at 32593. In other words, the August 13, 2018, amended skin rating criteria can be applied retroactively, if more favorable to the Veteran. See generally VAOPGCPREC 3-2000, 7-2003. As noted above, the Veteran's initial rating for his psoriasis was made effective January 17, 2012. Thus, his initial rating claim for psoriasis was pending prior to the August 2018, revisions. As such, the Veteran's initial rating claim for his psoriasis must be considered under the August 2018 amended rating criteria for the skin as well. Prior to August 2018, the rating criteria for psoriasis affecting less than five percent of the entire body, or of exposed areas, and requiring no more than topical therapy during the past 12-month period warranted a noncompensable rating. 38 C.F.R. § 4.118, DC 7816 (2017). Psoriasis affecting at least five percent, but less than 20 percent, of the entire body, or of exposed areas, or; requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period warrants a 10 percent rating. Id. Psoriasis affecting 20 to 40 percent of the entire body, or of exposed areas, or; requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period warrants a 30 percent rating. Id. Psoriasis affecting more than 40 percent of the entire body, or of exposed areas, or; requiring constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, during the past 12-month period warrants a 60 percent rating. Id. Diagnostic Code 7816 further provides that psoriasis may alternatively be rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. Id. The Board notes that the Court's holding in Johnson v. McDonald, 27 Vet. App. 497 (2016), provided that topical use of either corticosteroids or other immunosuppressive drugs is considered "systemic." Thereafter, in Johnson v. Shulkin, however, the United States Court of Appeals for the Federal Circuit (Federal Circuit) reversed this decision and determined that "constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs" is generally not inclusive of topical corticosteroids. 862 F.3d 1351, 1352 (Fed. Cir. 2017). The Federal Circuit found that "systemic therapy" meant "treatment pertaining to or affecting the body as a whole," while topical therapy meant "treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied." Id. at 1355 (citation omitted). The Federal Circuit also held that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole. Id. Thus, in a given case, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances. Following the Federal Circuit's decision, the Court again addressed "systemic therapy" in the context of topical treatment in Burton v. Wilkie, 30 Vet. App. 286 (2018). The Burton court stated that, when considering topical therapy as systemic therapy, the Federal Circuit's decision in Johnson was not limited to situations involving large-scale application of topical treatment. Id. at 291. Rather, the Court held that there are at least 2 other potential ways of showing that a topical treatment is systemic: (1) the method by which the topical treatment works, and (2) its side effects. Id. The August 2018 amendments to the skin rating criteria introduced a General Rating Formula for skin conditions, and amend Diagnostic Codes 7801 and 7802 by characterizing multiple scars by 6 body zones affected rather than by extremity. In addition, under the August 2018 amendments, two or more skin conditions may be combined in accordance with § 4.25, only if separate areas of skin are involved. If two or more skin conditions involve the same area of skin, then only the highest evaluation shall be used. See 38 C.F.R. § 4.118(b) (August 13, 2018). Under the new regulations, psoriasis is to be rated under the General Rating Formula for Skin, under which a noncompensable rating is to be assigned when no more than topical therapy is required over the past 12-month period, and when there are characteristic lesions involving less than 5 percent of the entire body affected, or involving less than 5 percent of exposed areas affected. Id. A 10 percent rating will be assigned if the disability meets at least one of the following: (i) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or (ii) at least 5 percent, but less than 20 percent, of exposed areas affected; or (iii) intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. Id. A 30 percent rating will be assigned if the disability meets at least one of the following: (i) characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (ii) systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. Id. A 60 percent rating will be assigned if the disability meets at least one of the following: (i) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (ii) constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. The General Rating Formula for Skin still provides that an applicable skin disability may alternatively be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), depending upon the predominant disability. As applied to the facts in this case, the Board finds that the rating criteria in effect prior to August 2018 are substantially similar to, and are as equally favorable to the Veteran as, the amended criteria. Turning to the evidence of record, Tricare records associated with the claims file, dated just prior to the appeal period from August 2011, through July 2012, reflect the Veteran's reports of having a rash on his hand, groin, buttocks, and gluteal cleft. Treatment noted included cortisone and hydrocortisone cream. In an August 2013 initial VA-contracted examination report, the examiner noted that the Veteran had not used any oral or topical medications for his diagnosed psoriasis in the past 12-month period, and he had not undergone any other treatment or procedures. Physical examination revealed psoriasis affecting less than five percent of the total body area and less than five percent of exposed areas. The examiner noted that the psoriasis was present on the hands, coccygeal area, and lower back. A subsequent May 2015 VA-contracted examination revealed that the Veteran had not been treated with any oral or topical medications, or undergone any other treatments or procedures over the prior 12-month period. His skin condition was noted to affect less than five percent of his total body area, and none of his exposed areas. The examiner noted that psoriasis appeared as a raised, erythematous patch, with interspersed erythematous papules and dry scaly skin in the right groin area, measuring 35 by 15 centimeters. A September 2017 VA-contracted examination report noted that the Veteran used topical corticosteroids, consisting of hydrocortisone, on a constant or near-constant basis over the preceding 12-month period. No other treatment or procedure was used to treat his psoriasis. The examiner assessed that the psoriasis affected less than five percent of the total body area and less than five percent of exposed areas. The examiner described the psoriasis as consisting of an erythematous plaque formation, without scaling, on the creases of right 4th and 5th metacarpophalangeal (MCP) joints, and proximal interphalangeal joint web between the 4th and 5th toes of the left foot and the right 5th toe. Erythematous plaque formation with scaling was also present just above the right inguinal area. In a January 2018 VA examination report, the examiner indicated that in 2013, the Veteran's psoriasis condition worsened. Psoriasis was noted on the Veteran's bilateral hands, groin region, and on the buttocks. The examiner noted that since 2013, the Veteran had had more dryness, skin cracks, and had started to experience bleeding on his hands. He used medicated cream which helped to control the condition. He also experienced more itching and more bleeding because of more dryness since 2013. Further, since 2013, the redness in the groin area and buttocks had spread more in those areas. Due to worsening since 2013, the Veteran has also been given more ointments and creams to help control the psoriasis condition, where in the past, he was only given one medication and was noted to now be on 2 different kinds of medication to help control the condition. The examiner assessed that the Veteran had used topical medications for six weeks or more, but not constantly, during the preceding 12-month period. The examiner indicated that the psoriasis affected from five to less than 20 percent of the Veteran's total body area and exposed areas. The Veteran was most recently afforded a VA-contracted examination in March 2018. The examiner noted that the Veteran used a topical ointment to treat psoriasis on a constant or near-constant basis. He did not use any other treatment or procedure to treat his psoriasis. The examiner equivocally indicated that the Veteran did not have any visible skin conditions, but later noted in the report that he had new lesions in the posterior neck and in the intergluteal region, and that he had hyperemic areas apparently in the posterior neck, groin, and intergluteal regions, affecting less than five percent of the total body area and less than five percent of exposed areas. The examiner noted that photographs were not indicated for this evaluation. All examination reports specifically indicated that the Veteran did not have scarring or disfigurement of the head, face, or neck. VA clinical treatment report dated from January 2019 to June 2019 revealed a varying degree of severity of a skin condition. The reports appear to indicate that the Veteran's skin disability had been assessed as tinea and seborrheic keratosis, affecting the groin and right temple, respectively. These reports, however, do not clearly indicate whether the Veteran continued to present psoriasis; nor do they assess the severity of the current conditions. Given the above, the Board finds that the evidence fails to show that the Veteran is entitled to a compensable disability rating prior to January 25, 2018. The evidence of record, including the August 2013, May 2015, and September 2017 examination reports, clearly indicates that the Veteran used no more than topical creams and ointments to treat his service-connected psoriasis, and that the skin condition did not at any point cover at least five percent of the total body area or exposed areas, as required for a compensable rating. Moreover, although the September 2017 examination report indicated that the Veteran used corticosteroids on a constant or near-constant basis, given that the skin condition affected less than five percent of his total body area, such treatment cannot be considered to have been administered on a large enough scale such as to affect the body as a whole, but rather it was applied only to certain areas of the skin, as contemplated by the Federal Circuit in Johnson. 862 F.3d at 1355. There was additionally no indication that any of the topical treatments functioned in a manner consistent with a systemic therapy, or that either had side effects such as to warrant a finding that it constituted systemic therapy, as contemplated in Burton. 30 Vet. App. 286. In reaching this finding, the Board notes that the January 2018 VA examination report indicated that the Veteran's psoriasis worsened in 2013, and that he had had more dryness, skin cracks, and had started to experience bleeding on his hands, the contemporaneous VA examination reports still indicate that the condition did not cover sufficient body area, or require systemic therapy, such as to warrant a compensable rating. As such, the preponderance of the evidence is against the Veteran's claim for a compensable rating for psoriasis prior to January 25, 2018. As for the appeal period as of January 25, 2018, the Board observes that the January 2018 VA examination report clearly indicated that the Veteran's psoriasis affected between five and less than 20 percent of the Veteran's total body area and exposed areas. Based on this examination finding, the Board finds that a 10 percent rating, but not higher, is warranted for service-connected psoriasis as of January 25, 2018. Although the subsequent March 2018 VA-contracted examination report indicated that the Veteran's psoriasis was of a lesser severity than as noted in the January 2018 report, the report provided contradictory evidence, first noting that the Veteran did not have a visible skin condition, but then noting that he had new lesions in the posterior neck and in the intergluteal region, and hyperemic areas in the posterior neck, groin, and intergluteal regions, affecting less than five percent of the total body area and less than five percent of exposed areas. Thus, affording the Veteran the benefit of the doubt, the Board finds that the March 2018 examination report is insufficient to find that a staged noncompensable rating is warranted as of the date of that examination. Notably, at no point during the period on appeal has the Veteran's psoriasis been shown to involve more than 20 percent of the entire body or of exposed area, or to require systemic therapy such as corticosteroids or other immunosuppressive drugs, or therapy such as, but not limited to phototherapy, retinoids, biologics, photochemotherapy, or PUVA. As such, there is no basis to find that a rating higher than 10 percent is warranted at any point during the appeal period. In reaching the foregoing decisions, the Board has considered the Veteran's assertions and findings as to his limitations due to experiencing skin cracking and bleeding of his hands due to service-connected psoriasis. The rating criteria specifically contemplate skin conditions affecting the pertinent parts of the body, even to a severe degree. However, the pertinent focus of the skin rating criteria is on the total body area affected and the required treatment for the condition. Here, the evidence has not shown that the Veteran has required more than topical medications or ointments for his service-connected psoriasis, even in the presence of dry, cracking skin of the hands; or that is has affected at least 20 percent or more of his total body area or exposed areas at any point during the appeal period. Thus, in spite of the Veteran's assertions that a higher rating is warranted, the medical evidence as to the required treatments and total affected areas is more probative. As such, in reaching the conclusion that a disability rating of 10 percent, but no higher, is warranted as of January 25, 2018, for the service-connected psoriasis, the Board has considered the assertions of the Veteran, but has relied on VA and VA-contracted examination reports, which duly considered his symptoms but did not show findings approximating the criteria for the next higher rating. REASONS FOR REMAND Higher Disability rating for PTSD with MDD After carefully considering the evidence of record, Board finds that the issue of entitlement to a higher rating for service-connected PTSD with MDD must be remanded for further development. A June 2018 letter from a Vet Center therapist indicated that the Veteran was receiving regular treatment for his mental health disorder symptoms at the Vet Center. The Vet Center treatment records, however, have not been associated with the claims file, and there is no indication as to whether they are otherwise available. Vet Center records are deemed to be in the constructive possession of VA. Dunn v. West, 11 Vet. App. 462, 466-67 (1998) (citing Bell v. Derwinski, 2 Vet. App. 611 (1992) (Vet Center records are generated by VA agents or employees which are deemed within the Secretary's control and, thus, are deemed constructively of record). Where no attempt has been made to obtain the Veteran's Vet Center records, remand is required to obtain these records. 38 C.F.R. § 3.159(c)(2). Accordingly, this matter is hereby REMANDED for the following action: Follow the procedures set forth in 38 C.F.R. § 3.159(c) to procure the following records from Federal facilities. Available records and all responses should be associated with the claims file: (a.) Obtain the Veteran's Vet Center treatment records, to include records dated in June 2018. If the Vet Center requires an authorization form to obtain records, provide him an authorization form to authorize release of these records. (b.) Obtain any additional outstanding VA clinical treatment records pertaining to the Veteran's mental health treatment. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate in ensuring the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). He is advised that he has the right to submit additional evidence and argument with respect to this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded prompt treatment. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael Wilson, 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.