Citation Nr: 21028113 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 11-22 383 DATE: May 10, 2021 ORDER Service connection for, or worsening of a skin disorder, secondary to diabetes mellitus and/or exposure to herbicides is denied. FINDING OF FACT The Veteran's diagnosed skin disorder was not caused by the Veteran's service and was not caused or aggravated by his service-connected diabetes mellitus and/or exposure to herbicides. CONCLUSION OF LAW The criteria to establish service connection for skin disorder, to include as secondary to diabetes mellitus and/or herbicides have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from September 1961 until September 1964. The Veteran died in mid- 2014, with his perfected claim pending on appeal. The appellant is the properly substituted party. See 38 U.S.C. § 5121A. The Board last remanded this appeal in December 2020 to obtain an addendum medical opinion. Service Connection Service connection may be granted for current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C. § 1110. 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). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310 (a) where it is demonstrated that a service-connected disorder has caused a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran was service connected for diabetes mellitus. In June 2018, VA granted service connection for diabetes mellitus, Type II on the basis that the Veteran was in Vietnam during his military service and because the Veteran's disorder was therefore presumed by law to have been caused by herbicide exposure. In the Veteran's July 1964 examination for service separation, the Veteran noted no complaints relevant to a skin disorder. However, in an October 2001 treatment note the Veteran was seen for a follow up appointment regarding an intradermal cyst. An October 2002 treatment note indicates a history of intradermal cysts with past cysts becoming infected and being removed. In a December 2003 treatment note, the Veteran was noted to have a lipoma on the back of his neck. The clinician referred the Veteran to another physician to have it surgically removed. In a March 2007 treatment note, the Veteran was reported to have surgery to remove two cysts on his back. In a June 2009 lay statement, the Veteran noted that he had blackheads and cyst-type lumps over his entire body, and he alleged that he had experienced these symptoms since shortly after service separation. The Veteran reported that this condition had worsened over time. Treatment records authored by J.L. Benedum, M.D. were received in October 2018. They reflect that had cysts lipomas removed from his posterior neck and chest in October 2008. However, there is no information as to the cause of these lipomata. A January 2010 statement from Dr. Benedum reflects that the Veteran had diabetes mellitus, hypertension, and several other medical conditions. The physician opined that the Veteran's longstanding diabetes mellitus was a major factor in his subsequent medical symptoms and complications. However, the physician did not mention the Veteran's lipomata or cysts in this letter. Other treatment records do not mention the cause of the symptoms. As noted, the Veteran died in mid-2014. His death certificate reflects the cause of death as a stroke, due to multi-organ failure. A skin disorder is not mentioned in the death certificate. In August 2018, the Veteran's file was reviewed by a VA examiner. The examiner noted that the Veteran began treatment for skin lesions in the early 2000's, decades after service separation. The examiner noted that the Veteran had been diagnosed with lipomata (rather than inclusion cysts) by his non-VA physician, and that the examiner reported no evidence of lesions in service. The examiner reported that this condition is not related to Agent Orange exposure or diabetes mellitus and often has an etiology related to genetics. In July 2020, the Veteran's file was reviewed by the same VA physician-examiner. The examiner reiterated the opinion of the August 2018 medical review and stated that the Veteran's lipomas were due to a genetic condition and unrelated to Agent Orange or diabetes mellitus. In January 2021, the Veteran's file was reviewed by the same VA examiner who conducted the July 2020 examination. The physician noted that the Veteran's skin condition was not aggravated or worsened at any time by service-connected diabetes or herbicides. The examiner stated that the Veteran had Lipomata which is a genetic condition when the patient develops multiple lipomas over time in different parts of the body. The examiner noted that lipomas are benign tumors. She also noted that there was no aggravation of the Veteran's lipomas because they never turned into malignant tumors, did not compress vital structures, and followed the natural progression of the symptoms. One of the critical components in a successful claim of service connection is that of causality of the disorder. In the case of a skin abnormality such as lipomata or cysts, it cannot be doubted that a competent medical opinion is necessary to determine etiology. The record does not contain any competent medical evidence indicating that the Veteran's lipomata or cysts was caused by any incident of military service, to include his service-connected diabetes mellitus or presumed exposure to herbicides. The claim will be denied on this basis. The appellant argues that the January 2021 VA examiner focused on "lipomas" instead of "cysts." Apart from the fact that the appellant has presented no evidence to support her assertion of a medical nexus, the examiner has reviewed the question of cause on at least three occasions, accompanied by a review of the record. The texts of her reports indicate that the examiner was clearly aware of the Veteran's medical history and she substantially complied with the Board's remand directives. Dyment v. West, 13 Vet. App. 141 (1999) ((holding that remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with)), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002); see also Hood v. Shinseki, 23 Vet. App. 295 (2009) (reaffirming that the mere fact that the Board did not obtain the specific report previously requested in Board remand is not necessarily a violation of Stegall, if expert opinion otherwise obtained was sufficient to address the relevant inquiry); D'Aries v. Peake, 22 Vet. App. 97 (2008) (substantial compliance, not strict compliance, is required under Stegall). There is also no question that the Veteran underwent surgical excisions of cysts. However, this fact is not directly relevant to the question of the etiology of the Veteran's cysts/lipomas. The appellant has also argued that the Veteran's treating physician had indicated the Veteran's cysts were the result of in-service exposure to herbicides. However, the evidence of record does not support this statement. The Veteran's physician has only stated that the Veteran's diabetes mellitus is the cause of other medical problems experienced by the Veteran. The Board has considered the appellant's assertions that the Veteran's skin disorder was caused by his service-connected diabetes. The appellant is not competent, however, to offer an opinion as to the etiology of this type of medical condition due to the medical complexity of the matter involved. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994). VA examinations/medical opinions have consistently concluded that the Veteran's skin condition is not the result of; or aggravated or worsened at any time by his service, to include his service-connected diabetes and/or herbicide exposure. In the January 2021 medical opinion, the examiner states that the Veteran's skin condition was Lipomata which progressed naturally. The Board also notes that there is no evidence of in-service cysts or lipomas. As noted above, a July 2020 VA examination also concluded that the Veteran's lipomas were the result of a genetic condition and not the result of the Veteran's service-connected diabetes or exposure to herbicides. The preponderance of the evidence is against the claim and the appeal is denied. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Wozniak, 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.