Citation Nr: 21028168 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 18-52 557 DATE: May 10, 2021 REMANDED Service connection for a skin disability manifested by cysts, to include hidradenitis and as due to herbicide exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1966 to December 1968. This case is before the Board of Veterans' Appeals (Board) on appeal from a December 2016 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that rating decision, the RO denied entitlement to service connection for a groin cyst. In May 2017, VA received the Veteran's Notice of Disagreement (NOD). In October 2018, the RO issued a Statement of the Case (SOC). In November 2018, VA received the Veteran's VA Form 9 appeal to the Board. In an August 2019 decision, the Board denied the Veteran's claim for service connection for a groin cyst. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (CAVC or Court). In an August 2020 Court Order granting a Joint Motion for Partial Remand (JMPR) the Court vacated the Board's August 2019 decision in part and remanded the case for further development in compliance with the directives specified in the JMPR. 1. Entitlement to service connection for a skin disability manifested by cysts, to include hidradenitis and as due to herbicide exposure. In the August 2019 decision, the Board concluded that the Veteran did not have a current diagnosis of groin cysts or any other skin disability, citing an October 2016 VA skin examination that purportedly revealed no evidence of groin cysts or abscesses. However, as noted by the August 2020 JMPR, VA treatment records reveal that medical providers have observed multiple cysts in the groin area during the period on appeal. Specifically, a March 2017 VA dermatology note reveals that the Veteran had a diagnosis of hidradenitis, manifested by cysts "mainly" affecting the groin, but also "occasionally [the] buttocks and armpits." The Veteran indicated that the groin cysts were a recurring condition; he noted experiencing them roughly "every other month." Furthermore, he reported "flares at least every 90 days and it is severe and debilitating," and making it "difficult to walk." During the visit, the treating VA physician observed "on the right inguinal crease, a tracking well healed scarred papule, non drainig (sic)" and "on the left inguinal crease near the scrotum, a well defined nodule without overlying secondary changes or drainage." Treatments included antibiotics (doxycycline), corticosteroids (tretinoin), and bleach baths "2-3x weekly." VA dermatology note dated March 8, 2017. As the August 2020 JMPR correctly concluded, the above evidence is inconsistent with the October 2016 examiner's finding that the Veteran did not have current diagnosis of groin cysts or any other skin disability; accordingly, the October 2016 examination report cannot support a decision on the claim. Given that the October 2016 examiner found that the Veteran did not have a current skin disability, the examiner also failed to provide an opine regarding nexus to service. However, the Veteran has reported onset of cysts during service with continuity of symptoms to the present. See VA dermatology note dated September 7, 2016. Moreover, during the October 2016 examination, the Veteran indicated onset of symptoms in 1967 and "an almost 50 years history of recurrent cysts and abscesses in his groin area." He received treatment including "incision and drainage and oral antibiotics down through the years by his primary care doctors." October 2016 VA examination report. Service treatment records (STRs) confirm that the Veteran had a pilonidal cyst lanced during service. See STRs dated March 8, 1968. Furthermore, post-service medical evidence dated as early as 1997 reveals a disability manifested by cysts in the groin region. In this regard, a private treatment record shows that the Veteran reported 2 cysts in the groin that "lasted x4 days"; however, the cysts had healed by the time of the visit. See private primary care clinic record dated October 6, 1997. Furthermore, a March 2010 VA ophthalmology note contains a brief reference to cyst incision and drainage in the Veteran's past symptom history. See VA ophthalmology history and physical note dated March 4, 2010. In light of the above, remand is warranted for a new VA examination for the Veteran's skin disability manifested by cysts. In the accompanying opinion, the examining dermatologist or other medical professional should address the lay and medical evidence identified by this Remand. Finally, the Veteran has asserted that his disability manifested by cysts is related to herbicide exposure during service. During service in the U.S. Army, the Veteran served within the Republic of Vietnam and was awarded a Vietnam Service Medal with 3 Bronze Service Stars, a Republic of Vietnam Campaign Medal, and a Purple Heart, among other decorations. See DD Form 214 uploaded on January 25, 2017. Therefore, he is presumed to have been exposed to herbicide agents during service. 38 C.F.R. § 3.307(a)(6)(iii). As hidradenitis (or other conditions manifested by cysts) is not on the lists of diseases under 38 C.F.R. § 3.309(e) as associated with herbicide exposure, service connection on a presumptive basis is unavailable. However, service connection may still be established on a direct basis. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Accordingly, the examining medical professional should also consider this theory of entitlement. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his skin disability manifested by cysts by a dermatologist or other appropriate medical specialist, to include hidradenitis and as due to herbicide exposure. The examiner must review the claims file, including a copy of this Remand, and indicate that the claims file was reviewed in the report. A rationale for all opinions must be provided. The examiner should state whether the Veteran's skin disability manifested by cysts, diagnosed as hidradenitis, at least as likely as not (a 50 percent probability or greater) had onset during service or is otherwise related to disease or injury in service, to include in-service herbicide exposure. In answering the above, the examiner should specifically address the following evidence: (a.) The March 1968 in-service diagnosis of and treatment for a pilonidal cyst. (b.) The October 1997 private primary care record describing 2 resolved cysts in the groin region. (c.) The March 2010 VA treatment record describing a history of cyst incision and drainage. (d.) The March 2017 VA dermatology note providing a diagnosis of hidradenitis, noting evidence of papules on the right and left inguinal creases, and various treatments, including corticosteroids, antibiotics, and bleach baths. (e.) The Veteran's lay statements regarding onset and continuity of his symptoms from service, including his statements regarding a history of recurring (roughly every other month) painful cysts mainly affecting the groin, but also the armpit and buttocks and treated with lancing and oral antibiotics prescribed by primary care providers during the years since service. If the examiner opines against a finding of in-service onset, then, regarding the claimed nexus to herbicide exposure, the examiner is advised that a negative opinion on this basis cannot be based solely on the fact that any skin diagnosis, including hidradenitis, is not on the list of diseases that are presumptively associated with exposure to herbicide agents. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Small, Attorney Advisor 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.