Citation Nr: 21027854 Decision Date: 05/07/21 Archive Date: 05/07/21 DOCKET NO. 17-40 872 DATE: May 7, 2021 ORDER Entitlement to service connection for fibromyalgia is denied. Entitlement to service connection for a skin disability is denied. FINDINGS OF FACT 1. The Veteran does not have fibromyalgia or a relevant undiagnosed illness or medically unexplained multisymptom illness. 2. A current skin disability did not manifest in service and is unrelated to service. CONCLUSIONS OF LAW 1. Fibromyalgia, or any other relevant disorder, was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131, 1117, 1118, 1137; 38 C.F.R. §§ 3.303, 3.317. 2. A skin disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131, 1117, 1118, 1137; 38 C.F.R. §§ 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1988 to October 1992. He had service in the Southwest Asia theater of operations in support of the Persian Gulf War. In February 2020 the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ). A copy of the transcript is of record. During the hearing, the VLJ clarified the issues on appeal, explained the concept of service connection, elicited relevant testimony from the Veteran, identified potential evidentiary defects, and held the file open for 90 days to allow the Veteran to submit additional evidence. These actions complied with the duties owed during a hearing set forth in 38 C.F.R. § 3.103. Service Connection Veterans are entitled to compensation from VA if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). Service connection may also be granted for any 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). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be warranted for a Persian Gulf Veteran who (1) exhibits objective indications; (2) of a qualifying chronic disability; (3) that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317; Gutierrez v. Principi, 19 Vet. App. 1 (2004). We note that "Southwest Asia" is defined as: Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, UAE, Oman, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and airspace above these locations. 38 C.F.R. § 3.317 (e). The Veteran's DD-214 shows he participated in Operations Desert Shield and Storm from August 1990 to April 1991 and that he was awarded the Southwest Asia Service Medal with two stars and the Kuwait Liberation Medal. Personnel records show he served aboard the USS Saginaw in the North Arabian Sea and the Persian Gulf. As he had qualifying service, the Gulf War provisions are for consideration. The term "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; or (B) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders (excluding structural gastrointestinal disorders). 38 C.F.R. § 3.317 (a)(2)(i). Objective indications of a 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. 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. Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317 (b). In addition to certain chronic disabilities from undiagnosed illness, service connection may also be given for medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs and symptoms, as well as for any diagnosed illness that the VA Secretary determines by regulation warrants a presumption of service connection. 38 C.F.R. § 3.317 (a)(2)(i)(B). 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; 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). 3. Fibromyalgia. The Veteran contends that he has fibromyalgia that manifested during service or is due to exposures during his service in Southwest Asia. Service treatment records show the Veteran complained of a cough, sore throat, congestion, and body aces in December 1988, and was assessed with viral syndrome. In August 1990, and while deployed on the USS Saginaw, he complained of body myalgia, sore throat, stiff neck, and headache for three days. He was assessed with a lower respiratory infection. At a follow up the next day, he complained of joint pains in the lower back and neck, sore throat, and headache. Lymph nodes were swollen. He was assessed with a lower respiratory infection and viral pharyngitis. The August 1992 separation examination shows a normal clinical evaluation of the upper and lower extremities, feet, spine, and other musculoskeletal systems. The Veteran denied a history of any relevant symptoms in a February 2006 report of medical history when he enlisted in the National Guard, and examination revealed all relevant systems were clinically normal. Post-service treatment records show that in December 2012 the Veteran complained of nausea and fatigue after slipping on ice onto his head and lying unconscious. He was assessed with a concussion and neck and back strain with spasm. In December 2015 the Veteran reported chills, dyspnea, cough, and fatigue that had started after remodeling a basement with a friend. Differential diagnoses included bronchitis (viral vs bacterial), pneumonia, and hypersensitivity pneumonitis. Considering slight leukocytosis, low procalcitonin, CXR pattern and body aches, bronchitis was more consistent with viral etiology. He was treated with a course of steroids and albuterol inhaler. The Veteran requested a Gulf War syndrome evaluation in January 2016, reporting that he had generalized pain, weakness, numbness/tingling, and narcolepsy. In March 2016 he was screened for participation in a Gulf War Illness Inflammation Reduction Trial number 4554-A. The respiratory examination was clear, cardiovascular examination showed regular rhythm, and the joint examination showed no synovitis and full active range of motion without pain. He was enrolled in the study in April 2016. In May 2016 the Veteran reported to his VA primary care physician that he was to have a Gulf War syndrome examination and that he was contacted and told that he has symptoms that can be related to or caused by Gulf War syndrome. He had no physical complaints at the time. physical examination revealed no joint swelling, that the Veteran ambulated without difficulty, and the back was negative. There were no neurological, strength, or sensation deficits and his gait was normal. No abnormalities were found, and the Veteran's physician noted that the Veteran was "as perplexed as I am as to what purpose was to be served by this visit." Records indicate the Gulf War Illness Inflammation Reduction Trial concluded in September 2016. The Veteran was paid for his participation in the trial. The records do not show any relevant diagnoses. In October 2016 the Veteran reported low thoracic back discomfort without injury and present for a week. He has had some back pain in the past, usually from an injury, but has not injured himself, strained himself, overworked or done anything new or excessive. He denied illness, and there were no new joint pains or arthritic changes. No weakness or neurological problems have been noted, and there was no footdrop, leg giving out, or sciatica. Physical examination showed muscular back spasm. There were no focal deficits, strength and sensation were normal, reflexes were noted as slightly diminished at the achilles and knee, and there were no sensory changes. He was assessed with a low thoracic back strain. The Veteran was provided a VA Gulf War general medical examination in October 2016. He reported that following military service he was a commercial diver for 20 years doing underwater construction, and that he experienced the bends multiple times. He had type 2 decompression sickness involving the elbow and shoulder, had skin bends with mottling after, and had severe back pain multiple times. He was also provided a VA examination for fibromyalgia in October 2016. The Veteran reported that he has intermittent random shooting pain in the knees and lips, hands, and legs. The pains were described as sharp split-second piercing pain and very intermittent, and "like a lightning bolt of pain." The pains did not repeat in a given area and had been happening for 3-5 years. There was no redness, warmth, swelling, or joint pain. He reported morning stiffness and that he gets tingling in his thighs and at times into his hips, which the examiner noted this is consistent with a diagnosis of meralgia paresthetica. He also reported fatigue lasting for a few days causing anxiety. The examiner concluded there was no diagnosis of fibromyalgia. She explained that the intermittent shooting pain is a not yet diagnosed illness, and there was no evidence that this had been evaluated. The Veteran worked for 20 years doing commercial diving including 30-day saturation dives at deep levels. He experienced the bends multiple times and reported that he had type 2 decompression problems. The longterm or late effects of decompression sickness includes neurologic abnormalities including sensory and paresthesias. The examiner concluded that it is more likely than not that Veteran's intermittent pain symptoms are caused by or the result of residual of his intervening career of commercial diving, and less likely as not that such currently yet undiagnosed symptoms are caused by or the result of his Gulf War exposure. He reported foot and back pain in February 2017 and reported that his back had "went out" in April 2017. A June 2017 treatment record shows the Veteran attributed foot and thigh pains to possible Gulf War syndrome. In November 2017 he reported aching pain in lower body starting at his waist and going down to his ankles, with no shooting pain, swelling, redness, numbness, or tingling. The Veteran testified at a Board hearing in February 2020. He reported that he was treated for fibromyalgia at Camp LeJeune during service but did not recall whether he was diagnosed, and that VA physicians had not diagnosed him with fibromyalgia. He also reported that he was a commercial diver after service, that he had the bends, and that he had been treated for decompression sickness. Regarding Camp LeJeune service, a veteran who had no less than 30 days (consecutive or nonconsecutive) of service at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987, shall be presumed to have been exposed during such service to the contaminants in the water supply, unless there is affirmative evidence to establish that the individual was not exposed to contaminants in the water supply during that service. 38 C.F.R. § 3.307 (a)(7). Although the Veteran's personnel records and service treatment records confirm he served at Camp LeJeune, he entered service in August 1988, well after the applicable presumptive period. As such, the Veteran may not be presumed to have been exposed to contaminants in the water supply at Camp LeJeune. There is no evidence that the Veteran was exposed to any contaminants at Camp LeJeune, and he denied any knowledge of such exposures at the February 2020 Board examination. Service treatment records are absent any relevant symptoms or complaints during his service at Camp LeJeune, and there is no evidence any current symptoms are related to his period of service at Camp Lejeune. The primary issue for the Board is whether the Veteran has fibromyalgia, or another undiagnosed illness or medically unexplained multisymptom illness, that either began during service or may be presumed to be related to his service in Southwest Asia. The Board concludes that the Veteran does not have fibromyalgia, or any other relevant illness, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107 (b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303. The probative value of a medical opinion primarily comes from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board accepts the October 2016 VA examiner's opinions that the Veteran does not have fibromyalgia and that his symptoms are less likely than not caused by or the result of his Gulf War exposure as probative medical evidence on this point. The Board notes that the examiner rendered the opinions after thoroughly reviewing the claims file and interviewing the Veteran. The examiner noted the Veteran's pertinent history and provided a reasoned analysis of the case. See Hernandez-Toyens v. West, 11 Vet. App. 379, 383 (1998); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). The Veteran's representatives have challenged the October 2016 VA examiner's competency to provide the opinion. The representative alleged that examiner gave a negative opinion with no basis for the opinion, and falsely related the Veteran's symptoms to a non-service-connected event (decompression illness) even though the symptoms are not known to be residuals of decompression sickness. The representative alleged the examiner is not qualified to give the opinion that the conditions were related to decompression sickness as it is outside the scope of the examiner's practice, education, and training. Because the examiner is not a certified pulmonologist specializing in deep sea diving illnesses. See April 2017 Notice of Disagreement. The representative also submitted an article titled "Long Term Effects of Sport Diving." We note that the article provided by the Veteran's representative reflects that pains, fatigue, and neurologic symptoms such as paresthesias are associated with the long-term effects of diving. This directly contradicts the argument that the Veteran's symptoms are not known to be residuals of decompression sickness, and that the examiner falsely related the Veteran's symptoms to decompression illness. Furthermore, a pulmonologist would not be required to render an adequate opinion, as the Veteran has not alleged any pulmonary symptoms are related to his claim for fibromyalgia. Finally, with or without the negative VA opinion, the evidence does not show that the Veteran has fibromyalgia, or any other illness related to his Gulf War service, or that any disability is otherwise related to his service. In a statement submitted with the December 2017 VA Form 9, the Veteran's representative argued the October 2016 examination is invalid because a registered nurse gave an unsupported opinion citing deep sea diving with no supporting rationale or documentation to validate the opinion. However, the VA examiner was a medical doctor, and the opinion is supported with rationale and based on the Veteran's documented reports of decompression illness with type 2 complications. The Board is entitled to accept the competence of a VA examiner and specific challenges to a VA examiner's competency must be raised by the Appellant to overcome this presumption. See Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009); see also Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). Here, the examiner's competency is challenged because she was not a pulmonologist and because decompression sickness was outside the scope of her practice, education, and training. Although the VA examiner's specialty is not noted on the examination reports themselves, the examiner was a medical doctor and carried the title of "C&P Staff Physician." The VA examiner has a medical background enough to give a competent opinion. As explained above, a pulmonologist would not be required to give an opinion. Thus, we find that additional evidence or compelling argument has not been submitted to indicate that the VA examiner is not otherwise qualified to offer nexus opinions pursuant to 38 C.F.R. § 3.159 (a)(1). Accordingly, the Board finds that the VA examiner is competent, and the nexus opinion offered was adequate for adjudication purposes. Furthermore, there is nothing in the argument by the representative that would establish a lack of competence to establish or reject a diagnosis of fibromyalgia. In regard to an assertion that a pulmonologist is needed to establish either a diagnosis of a Gulf War illness or residuals of the bends, we see no merit to the argument that a pulmonologist is needed to establish a musculoskeletal issue. The Veteran submitted an April 2020 nexus opinion from Dr. R., a VA primary care physician who had treated the Veteran from July 2017 to May 2018. Dr. R. determined that fibromyalgia was caused by or a result of Gulf War exposure and "Research Protocol 4554-A" and was as most likely caused by or a result of Gulf War exposure. Dr. R. explained fibromyalgia was more likely than not related to exposures experienced during the Veteran's military service because "the condition was noted and the Veteran was involved in a research protocol (4554-A) as noted in May of 2016." The Board finds this opinion to be of almost no probative weight. We accept that fibromyalgia, if it exists, may be related to the Gulf. Although Dr. R. based the opinion on a review of relevant VA treatment records, such records are absent any indication that the Veteran has fibromyalgia. Subsequent VA treatment records are absent any relevant diagnosis. To the extent Dr. R. may have intended to diagnose fibromyalgia, the opinion appears based on the Veteran's self-diagnosis, the fact that the Veteran filed a claim for fibromyalgia, and Dr. R.'s determination that the "condition was noted" in treatment records. As explained above, the Veteran is not competent to diagnose fibromyalgia, and fibromyalgia is not noted at any time in any treatment record. Opinions based upon an inaccurate factual premise have no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Dr. R. also did not address the Veteran's post-service career as a commercial diver and history of decompression illnesses. Furthermore, the Veteran's participation in the 4554-A research protocol does not show the Veteran has fibromyalgia. No such diagnosis was rendered during the Veteran's participation in the study, and VA treatment records contemporaneous with the study show he denied any relevant symptoms. The statement of Dr. R is remarkably lacking in findings that would justify a diagnosis of fibromyalgia. The Veteran testified at the February 2020 Board hearing that he had not been diagnosed with fibromyalgia, but that he believed he had been treated for fibromyalgia during service. There is no fibromyalgia documented in the available VA treatment records, nor is any such disease shown in the service treatment records. The Veteran was treated for viral infections that appear to have resolved by the time he separated from service. The relevant musculoskeletal systems were clinically normal at separation in 1992, and he denied any history relevant symptoms or diseases in a 2006 report of medical history. There is otherwise no competent evidence of record suggesting a connection between his in-service respiratory viral infections and his current symptoms. There is no acceptable proof of fibromyalgia documented in any medical record. The preponderance of the evidence is against finding the Veteran has fibromyalgia or any other disorder that may be considered an undiagnosed illness or medically unexplained multisymptom illness. VA treatment records during the pendency of the claim do not show any finding of fibromyalgia or another relevant Gulf War illness. There are indications of pain and fatigue, but no mention of fibromyalgia. The Veteran also regularly denied having relevant symptoms. While the Veteran is competent to testify as to his personal experiences, including symptoms, he is not competent to conclude that his in-service manifestations or his current symptoms are fibromyalgia, or that any current disability is related to his Gulf War exposures. Making such diagnoses and connections requires specialized education, training, or experience that the Veteran does not possess. 38 C.F.R. § 3.159 (a)(2); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The contemporaneous records establish that, while there were relevant manifestations in service, such were attributed to viral infections, which were identifiable clinical diagnoses. The service treatment records also show these infections had resolved by the time the Veteran separated in 1992. There is no competent, probative evidence linking the in-service manifestations with the Veteran's current Veteran's claimed disorder to service. In summary, the Veteran has never been found to have fibromyalgia or other qualifying undiagnosed illnesses or medically unexplained multisymptom illnesses under the law governing compensation to Persian Gulf veterans. Although the Veteran experienced viral infections causing relevant during service, no competent evidence has been presented showing a nexus between his current symptoms and his in-service symptoms. No relevant symptoms were present at the separation examination in August 1992, and he denied any history of relevant symptoms in a 2006 medical history at enlistment into the National Guard. The VA examiner determined that the Veteran's current symptoms are more likely due to his history of decompression sickness during his post-service career as a commercial diver. No probative evidence to the contrary has been presented. There is no indication any of his symptoms are related to his service at Camp Lejeune. While the Veteran has a current disability, the preponderance of the evidence is against finding a nexus to the Veteran's service on a direct basis and against service connection under Gulf War provisions. As the preponderance of the evidence is against the claim, there is no doubt to be resolved, and the claim for service connection for fibromyalgia must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 4. Skin disability. The Veteran seeks service connection for a skin disability. He primarily contends that he has a skin condition on his face, ears, and legs due to exposures to contaminants during his Gulf War. At the February 2020 Board hearing, the Veteran's representative also raised the theory that a disorder could be due to the Veteran's service at Camp LeJeune. Service treatment records show the Veteran was treated for poison ivy on his hands, forearms, and behind his right ear in May 1989. The STRs do not show other treatments, complaints, symptoms, or diagnoses of a skin disability. The August 1992 separation examination reveals a clinically normal evaluation of the skin and lymphatic system. A February 2006 National Guard enlistment examination shows a clinically normal evaluation of the skin. He denied any history of skin diseases in a February 2006 report of medical history. Post-service VA treatment records shows the Veteran had an actinic keratosis on his left ear frozen with liquid nitrogen in April 2014. At a June 2014 followup appointment, the Veteran reported that the left ear lesion had returned and that he had noticed an itchy lesion on his right neck that had been there for about a week. Physical examination showed a raised erythematous lesion on the right neck skin with centrally normal appearing skin consistent with a dermatophyte lesion. The right ear auricle had a firm lesion. He was assessed with a small ear lesion, either fibrosis or a cartilaginous protrusion, and a dermatophytic infection of the right neck. June 2015 primary care notes show changes of the crura of the antihelix of the left ear that appeared to be firm and not a skin change. There were otherwise no skin changes. A March 2016 screening for a Gulf War Illness Inflammation Reduction Trial showed a verrucous scaly lesion of the left ear helix with no other rashes. Skin screens were negative in May 2016, showing no rashes or erythema and no worrisome skin changes. The Veteran was afforded a VA skin diseases examination in October 2016. The examiner diagnosed prior diagnoses of dermatophytosis and actinic keratosis. He reported no skin problems during service and that his current problems had began about five years prior. He reported intermittent skin conditions on his chin, inner aspect of ear, and behind his right ear that he was told was ringworm. Physical examination showed a scabbed abraded area on the chin which the Veteran rubbed frequently during the examination. The left inner ear had a firm nodular area on the inner cartilage with normal skin over it, which the examiner noted had been described by ENT specialists as fibrosis or cartilaginous protrusion. The examiner noted the current chin findings are consistent with chronic irritation from rubbing/scratching/picking. There was no current evidence of a fungal infection. The examiner concluded there is no evidence that the chin irritation would be caused by or the result of Gulf War exposure and is more likely due to his frequent rubbing and picking at the chin as demonstrated during exam. Regarding the ear lesion, there was no diagnosis of a skin condition. The examiner explained the lesion is below the skin and appears to be a cartilaginous lump or fibrosis of uncertain etiology. The examiner noted the Veteran boxed in the past and such injuries can lead to changes of the pinna. A June 2017 primary care record shows skin was clear but with a lesion on the right cheek with a tan. The Veteran established treatment at a new VA medical center in November 2019. He denied any rashes, itching, dryness, or suspicious lesions, and physical examination showed no skin rashes or lesions. The Veteran and his wife testified at a Board hearing in February 2020. He reported that he did not remember being treated for skin conditions during service and that he was told during VA treatments that he had ringworm on his face and that he likely had skin cancer. He reported an intermittent burning sensation on his ears and face that built a callous and flaked, and that he had itchy raised bumps on his legs a couple times per year. The Veteran submitted an April 2020 nexus opinion from Dr. R., the VA primary care physician who had treated the Veteran from July 2017 to May 2018. Dr. R. determined the Veteran's chronic skin condition is more likely than not related to Gulf War exposures because "the condition was noted and the Veteran was involved in a research protocol (4554-A) as noted in May of 2016." After reviewing the evidence, the Board concludes that service connection for a skin disability is not warranted. Regarding Camp LeJeune service, as explained above the Veteran may not be presumed to have been exposed to contaminants during his service as he entered service after the relevant presumptive period had expired. There is no evidence that the Veteran was exposed to any contaminants at Camp LeJeune, and he denied any knowledge of such exposures at the February 2020 Board examination. There is otherwise no indication that skin disorder is related to his period of service at Camp LeJeune. We also find that the Gulf War provisions are not applicable here, as there are identifiable clinical diagnoses for actinic keratosis, fibrosis, cartilaginous protrusion, and a dermatophytic infection. Unexplained rashes or other dermatological signs or symptoms may be manifestations of an undiagnosed illness or a chronic multisymptom illness under 38 U.S.C. § 1117 (g). Although the October 2016 VA examiner noted the Veteran's left ear cartilaginous lump or fibrosis was of unclear etiology, she also determined such did not represent a skin disorder. There is no probative indication that the left ear nodule is a manifestation of an undiagnosed illness or a chronic multisymptom illness within the meaning of 38 C.F.R. § 3.317. Despite lacking formal diagnosis or treatment, the Veteran's intermittent leg bumps are not shown to be representative of an undiagnosed illness or diagnosed medically unexplained chronic multisymptom illness within the meaning of the applicable law. The Veteran is not competent to make such an etiological determination. Therefore, presumptive service connection for a skin disorder under the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 is not warranted. For a medical opinion (i.e., medical evidence) to be given weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). The probative value of a medical opinion primarily comes from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. Id. at 304. We acknowledge the April 2020 nexus opinion submitted by Dr. R. and find the opinion to be of little probative weight. We note that Dr. R. treated the Veteran and reviewed relevant medical records from April 2014 to May 2018. However, the provided rationale simply indicates that a skin condition had been "noted" and the Veteran had participated in a Gulf War research protocol in May 2016. The probative value of a medical opinion primarily comes from its reasoning. There is no explanation as to why any skin disorder the Veteran had been assessed with during the period relevant to the appeal was related to Gulf War exposures. Reviewing the treatment records associated with Research Protocol 4554-A, there is no indication any skin disorder was identified as part of the study. The March 2016 screening examination for the trial did show a verrucous scaly lesion on the Veteran's left ear. However, Dr. R.'s conclusory rationale offers no reasoning why this lesion would be associated with Gulf War exposures. While there is no reasons-or-bases requirement imposed on examiners, they must support their conclusions with an analysis that the Board can consider and weigh against contrary opinions. Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In comparison, we find the October 2016 VA examiner's opinions to be probative evidence as to whether a skin disability is related to Gulf War exposures. At the time, the Veteran had only chin irritation and a lesion on his left ear. The examiner concluded the chin irritation was likely due solely to the Veteran's frequent rubbing and picking at the chin, and that the left ear lesion was not a skin condition but rather a cartilaginous lump or fibrosis. There was no active fungal infection, or any other identifiable skin disorder. The examination report and the examiner's opinion is generally consistent with the remaining medical evidence of record. the record is silent any fungal infection following the Veteran's treatments for dermatophytosis in 2014, and he has regularly denied the presence of any skin rashes or lesions since. Only a lesion on his cheek was noted in 2017 with no followup, and he denied any skin symptoms in November 2019. We note Veteran's testimony that he was told during VA treatments that he likely had skin cancer. VA treatment records do not show any diagnosis or treatments for skin cancer. He was assessed with actinic keratosis on his left ear in April 2014 and had a lesion on his right cheek, but there is no evidence he has been assessed with cancer. The Veteran has generally not contended that a current skin disability began during service. While he had poison ivy during service, it appears to have resolved shortly after treatment in May 1989 and was not present at the August 1992 separation examination. No skin disorder was identified when the Veteran entered the National Guard in February 2006. The Veteran's skin problems manifested in approximately April 2014 when he reported a new onset of the lesion on his ear, over 20 years after the Veteran separated from service. Although the presence of symptoms is not the same thing as seeking treatment for symptoms, this long period of time without evidence of seeking treatment has a tendency to weigh against the claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Skin conditions are first reported in the record years after service and have not been attributed by any competent evidence to service. 38 C.F.R. § 3.303. Although Dr. R. attributed a chronic skin condition to Gulf War exposures, the opinion is of little probative weight. No other health care provider has opined that any current skin disorder was present in service or is otherwise related to service. The Board has considered the lay statements of record. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay people are competent to testify to visible or otherwise observable symptoms of disability. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). The Veteran is competent to report the symptoms he experiences relating to his skin disorders. The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan, 451 F.3d at 1337. However, the medical record is silent for any skin disorders until 2014, when the Veteran reported his left ear lesion. Clinical notes at the time indicate this was a new onset problem. Medical records are otherwise silent regarding any burning lesions or rashes on the Veteran's face and legs. We again note that the Veteran has not contended that his current skin disorders began during service, nor do the service treatment records show that a current skin disorder was manifest during service. To the extent that the Veteran argues in support of this claims, his contentions are less probative than the medical record, his denials of any relevant symptoms at separation from service and when he enlisted in the National Guard in 2006, and the lack of any probative evidence suggesting a link between service and the current skin conditions. In summary, the evidence establishes the Veteran's skin was normal upon separation from service and the onset of the current skin disorders occurred many years after service. The Board finds that the contemporaneous in-service and post-service treatment records are entitled to greater probative weight and credibility than the lay statements of the Veteran. The more probative evidence does not show that the claimed disorders are related service, to the Veteran's Persian Gulf service or service at Camp LeJeune. The Board also finds the VA examiner's opinions to be more probative than the opinion the Veteran submitted in support of his claim. The preponderance of the evidence is against the claim, and the benefit-of-the-doubt doctrine does not apply. The claim for service connection for a skin disability must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). H. N. SCHWARTZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morse 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.