Citation Nr: 21028434 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-31 426 DATE: May 11, 2021 ORDER Entitlement to an initial compensable rating for erythema multiforme is denied. FINDING OF FACT During the period on appeal, the Veteran's service-connected erythema multiforme has not manifested in compensable symptoms; no residual disfigurement or scarring attributable to erythema multiforme. CONCLUSION OF LAW The criteria for a compensable initial rating for erythema multiforme have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.118, Diagnostic Code 7827. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had a period of Active Duty for Training (ACDUTRA) from March 2007 to July 2007 and served on active duty from March 2011 to June 2012. He had service in Afghanistan. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision by the Department of Veterans Affairs (VA). The Board remanded this matter in January 2019 so that the Agency of Original Jurisdiction (AOJ) could consider evidence associated with the record since the May 2016 Statement of the Case. The AOJ issued a Supplemental Statement of the Case in November 2020 and the appeal was thereafter recertified to the Board. 1. Increased rating for erythema multiforme. The Veteran seeks a compensable initial rating for erythema multiforme. Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran's service-connected erythema multiforme is currently assigned a noncompensable rating pursuant to Diagnostic Code 7827, which pertains to erythema multiforme and toxic epidermal necrolysis. Effective August 13, 2018, VA amended its regulations governing skin disabilities. Claims pending prior to the effective date, as in this case, will be considered under both old and new rating criteria. Under the old version of Diagnostic Code 7827, a 10 percent evaluation is warranted for recurrent episodes occurring during the past 12-month period that respond to treatment with antihistamines or sympathomimetics, or one to three episodes occurring during that past 12-month period requiring intermittent systemic immunosuppressive therapy. A 30 percent evaluation is warranted for recurrent episodes occurring at least four times during the past 12-month period, requiring intermittent systemic immunosuppressive therapy. A 60 percent rating is warranted for recurrent debilitating episodes occurring at least four times during the past 12-month period despite ongoing immunosuppressive therapy. See 38 C.F.R. § 4.118, Diagnostic Code 7827 (2012). Erythema multiforme may also be rated as disfigurement of the head, face, or neck under Diagnostic Code 7800, or as scars under Diagnostic Codes 7801, 7802, 7803, 7804, or 7805 depending upon the predominant disability. Id. Under the new version of Diagnostic Code 7827, a 10 percent evaluation is warranted for at least one of the following: one to three episodes of mucosal, palmar, or plantar involvement not impairing mastication, use of hands, or ambulation, occurring over the past 12-month period and requiring intermittent systemic therapy; or without recurrent episodes, but requiring continuous systemic medication for control. A 30 percent evaluation is warranted for all of the following: recurrent mucosal, palmar, or plantar involvement not impairing mastication, use of hands, or ambulation, occurring four or more times over the past 12-month period, and requiring intermittent systemic therapy. A 60 percent evaluation is warranted for recurrent mucosal, palmar, or plantar involvement impairing mastication, use of hands, or ambulation occurring four or more times over the past 12-month period despite ongoing immunosuppressive therapy. See 38 C.F.R. § 4.118, Diagnostic Code 7827 (2021). For the purposes of new Diagnostic Code 7827, systemic therapy consists of one or more of the following treatment agents: immunosuppressives, antihistamines, or sympathomimetics. Id. The new version of Diagnostic Code 7827 still states that erythema multiforme may also be rated as disfigurement of the head, face, or neck under, or as scars, depending upon the predominant disability. Id. Diagnostic Code 7801 provides that burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) will be assigned a 10 percent rating. Note (1) indicates that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. Diagnostic Code 7802 pertains to burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. A 10 percent rating is assigned for scarring of an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802. We note that the old version of Diagnostic Code 7802, applicable prior to August 13, 2018, pertained to superficial nonlinear scars. Note (1) indicated that a superficial scar is one not associated with underlying soft tissue damage. Diagnostic Code 7803 was removed effective October 23, 2008 and is therefore inapplicable to the Veteran's claim. Diagnostic Code 7804 pertains to unstable or painful scars. One or two scars that are unstable or painful are rated at 10 percent disabling. Note (1) to DC 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7804. Diagnostic Code 7805 specifically provides that any disabling effects not considered in a rating provided under Diagnostic Codes 7800-7804 should be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. After considering the evidence, the Board concludes that a compensable rating for erythema multiforme is not warranted under either version of Diagnostic Code 7827. Furthermore, a compensable rating is not warranted under any Diagnostic Codes for disfigurement or scars March 2012 service treatment records show macular lesions and a rash on the Veteran's arms, legs, and trunk consisting of circular erythematous macular lesions, and a dermatologist assessed him with erythema multiforme major. He was medevaced from Afghanistan and hospitalized. An April 4, 2012 service treatment records indicates he was cleared medically of his lesions and educated not to take NSAIDS. The Veteran had a VA dermatology consultation in October 2013. A total skin check was performed, including the arms, hands, back, chest, abdomen, head, and neck. Pigmented macules and papules of the trunk, head, neck, and extremities were identified, and the Veteran was assessed with compound nevi. His history of erythema multiforme was noted, and he was advised to avoid ibuprofen. The Veteran was provided multiple VA disability benefits questionnaire (DBQ) examinations in December 2013. On the Gulf War general medical examination, the Veteran reported erythema multiforme after taking ibuprofen in Afghanistan, and that the erythema multiforme had caused scars. The December 2013 skin diseases DBQ reflects a diagnosis of erythema multiforme in 2012 and compound nevi. There was no scarring or disfigurement of the head, face, or neck. Skin conditions did not require treatment with oral or topical medications in the past 12 months, and there were no debilitating or non-debilitating episodes in the past 12 months. Physical examination showed no abnormal skin conditions. The December 2013 scars and disfigurement DBQ shows superficial, nonlinear multiple blotches and patches of scarring to both upper extremities, both lower extremities, and the anterior and posterior trunk. The examiner noted that this scarring was mainly on the Veteran's upper arms, and opined that it was at least as likely as not that the Veteran's "skin discoloration to mainly his bilateral upper arms is residuals of erythema multiforme that [the Veteran] was treated for while in service." February 2015 dermatology notes show a full-body skin examination that included the scalp, face, ears, neck, chest, abdomen, back, right arm, left arm, right leg, left leg, buttocks, and genital organs. The examination revealed an eczematous patch on the left wrist, pigmented papules on the right neck, brown and tan macules, dry rough patches of skin on lateral arms, mid back, and thighs, and inflamed hair follicles He was assessed with probable eczematous dermatitis on the wrist, epidermal nevus, melanocytic nevi, folliculitis, and keratosis pilaris. Notably, the keratosis pilaris was present on the arms, back, and thighs. Moisturizers were recommended. No scarring or symptoms specific to erythema multiforme were identified. January 2016 dermatology notes show a history of eczema and folliculitis that is well controlled and that the Veteran moisturizes with Eucerin cream. A skin check of the arms, hands, back, chest, abdomen, head, and neck showed pigmented macules and papules consistent with nevi, keratotic papules consistent with seborrheic keratosis, epidermal nevus and melanocytic nevi, and mild folliculitis. He was provided a VA skin diseases examination in March 2016. The examiner noted a diagnosis of erythema multiforme, resolved with no intake of ibuprofen. The Veteran reported blotches and skin peeling all over his body, and that he uses special shampoo, body creams, and lotions with flares of his skin. No scarring or disfigurement of the head, face, or neck were noted. Erythema multiforme did not require treatment with oral or topical medications in the past 12 months, and there were no debilitating or non-debilitating episodes in the past 12 months. Physical examination showed no listed skin conditions. The examiner noted that the Veteran had been diagnosed with probable eczematous dermatitis and keratosis pilaris for which he is on Eucerin cream and Fluocinonide ointment. The Veteran was also diagnosed probable folliculitis and placed on selenium sulfide shampoo. The examiner explained these skin disorders are separate and mutually exclusive disorders than the erythema multiforme. January 2018 dermatology notes show the Veteran was moisturizing with Eucerin cream for eczema and was not using topical corticosteroids. He was using body washes, selenium sulfide shampoo for folliculitis. Physical examination showed eczema/atopic dermatitis, epidermal nevus, melanocytic nevi, keratosis pilaris, folliculitis, and skin tags. His history of erythema multiforme was noted, as was an allergy to ibuprofen. The Veteran was provided a VA examination for skin diseases in October 2020. The examiner determined the Veteran did not have a current skin condition. She explained that erythema multiforme is a hypersensitivity reaction that is triggered with NSAIDs, and it is not present as long as NSAIDs are avoided. Here, the preponderance of the evidence shows the Veteran has not met the criteria for a compensable rating under the old or new versions of Diagnostic Code 7827 during the period on appeal. While the Veteran has had manifestations of multiple other skin disorders during the pendency of his appeal, he has had remarkably few, if any, manifestations of erythema multiforme. Under the old version of Diagnostic Code 7827, a 10 percent rating requires recurrent episodes occurring during the past 12-month period that respond to treatment with antihistamines or sympathomimetics, or one to three episodes occurring during that past 12-month period requiring intermittent systemic immunosuppressive therapy. There is no indication that the Veteran had recurring episodes of erythema multiforme that required any treatment. There is little evidence of any erythema multiforme during the period on appeal, let alone antihistamine, sympathomimetic, or immunosuppressive therapy. A 10 percent evaluation under the new version of Diagnostic Code 7827 is warranted for one to three episodes of mucosal, palmar, or plantar involvement not impairing mastication, use of hands, or ambulation, occurring over the past 12-month period and requiring intermittent systemic therapy; or without recurrent episodes, but requiring continuous systemic medication for control. Again, there is no indication that the Veteran has had an episode of erythema multiforme during the period on appeal. Although he has used various lotions during the period on appeal, they are not systemic therapies within the meaning of Diagnostic Code 7827 (immunosuppressives, antihistamines, or sympathomimetics) and they were not prescribed to treat erythema multiforme. Rather, he is being treated for eczema, dermatitis, and folliculitis. Similarly, for ratings higher than 10 percent both the new and old versions of Diagnostic Code 7827 require episodes and manifestations of erythema multiforme requiring systemic or immunosuppressive therapy. There is no evidence the Veteran has had any episodes or manifestations of erythema multiforme since June 14, 2012, and although other skin disorders have required lotions and prescriptions, erythema multiforme has not required systemic or immunosuppressive therapy. As such, a 30 or 60 percent rating is not warranted. We have also considered whether the Veteran's erythema multiforme is more appropriately rated under other diagnostic codes. As noted above, erythema multiforme may also be rated as disfigurement of the head, face, or neck under Diagnostic Code 7800, or as scars under Diagnostic Codes 7801, 7802, 7804, or 7805 depending upon the predominant disability. There is no indication that erythema multiforme caused any disfiguration of the head, face, or neck. Multiple VA examinations are negative for any such disfigurement. As such, assigning a compensable rating for erythema multiforme under Diagnostic Code 7800 is not appropriate. Diagnostic Code 7801 requires scarring associated with underlying soft tissue damage, of which there is no evidence. Diagnostic Code 7802 applies to superficial nonlinear scarring and scarring not associated with underlying soft tissue damage. A compensable 10 percent rating requires the scarring be of an area or areas of 144 square inches (929 sq. cm.), of which there is no evidence. We acknowledge that the December 2013 VA examiner identified skin discoloration and blotchy patches on the Veteran's extremities and trunk, and determined the blotches were residual scarring associated with erythema multiforme. However, such scarring has not been identified by any other medical professional. In October 2013 a VA dermatologist identified only pigmented papules of trunk, head and neck, and extremities and assessed compound nevi. Subsequent VA dermatology examinations reveal no symptoms associated with erythema multiforme, including scarring. February 2015 dermatology notes show a full-body skin examination was completed, revealing probable eczematous dermatitis, a history of erythema multiforme, epidermal nevus, benign melanocytic nevi, and keratosis pilaris. Notably, the keratosis pilaris were described as dry rough patches of skin on lateral arms, mid back, thighs, the same locations identified by the December 2013 examiner. The March 2016 VA examiner determined the Veteran had eczematous dermatitis and keratosis pilaris that are separate and exclusive from the erythema multiforme. The October 2020 VA examination showed no current skin condition or scarring attributable to erythema multiforme. Given the foregoing, the Board finds the preponderance of the evidence weighs against finding residual scarring attributable to the Veteran's erythema multiforme. We note that, even if scarring were attributable to erythema multiforme, no evidence suggests any scarring covers 144 square inches (929 sq. cm.) or more. Diagnostic Code 7804 pertains to unstable or painful scars. There is no evidence any scarring attributable to the Veteran's erythema multiforme is unstable or painful. Finally, Diagnostic Code 7805 would not allow for a compensable rating under any other appropriate diagnostic code because the Veteran's erythema multiforme does not manifest in compensable symptoms under any other diagnostic code. Although VA dermatology records show ongoing treatments for multiple skin disorders, there is little indication that he is being treated for erythema multiforme beyond being advised not to use NSAIDS. The only probative evidence addressing the etiology of these other skin disorders is the March 2016 examiner's statement that such are separate disorders from the erythema multiforme. In sum, the preponderance of the evidence shows no compensable symptoms of erythema multiforme during the period on appeal. Other diagnostic codes are not applicable. As such, entitlement to a compensable rating for erythema multiforme is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). In reaching this conclusion, we acknowledge that multiple other skin disorders have been diagnosed. Consideration of non-service-connected pathology may not be considered in the evaluation of the service-connected disability and examiners have clearly distinguished the manifestations. 38 C.F.R. § 4.14. The Veteran's August 2014 Notice of Disagreement and June 2016 VA Form 9 reflect his contentions that these additional skin disorders are related to the service-connected erythema multiforme. Entitlement to service connection for another skin disorder is not before the Board. The Veteran is at liberty to file an appropriate claim. 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.