Citation Nr: 21028644 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-48 733 DATE: May 11, 2021 ORDER Entitlement to service connection for a skin disability is denied. Entitlement to service connection for a bilateral knee disability is granted. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran's skin disability began during service or is otherwise etiologically related to service. 2. Resolving reasonable doubt in the Veteran's favor, his bilateral knee condition had its onset during service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a skin disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for a bilateral knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1974 to December 1977. The matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in July 2018. The hearing transcript is of record. The Board remanded the claim in August 2018, October 2019, March 2020, and February 2021 for further development by the RO. The case has been returned to the Board for further appellate action. SERVICE CONNECTION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 1. Entitlement to service connection for a skin disability The Board finds that the Veteran's skin disability did not have its onset in service and is not otherwise related to service, thus warranting denial of an award of service connection. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a). The record in this case is clear as to whether the Veteran has a skin disability. The post-service VA examination reports reflect a diagnosis of eczema. See VA examination reports dated October 2019 and November 2020. Thus, the first element of service connection, the existence of a current disability, is satisfied. Concerning the in-service event, illness, or injury, the Veteran's service treatment records (STRs) contain records of complaints, treatment, or diagnosis of skin-related symptoms during service. An August 1975 record notes a growth; the impression was a small cyst. An August 1975 record notes a two-week history of a rash on the abdomen, back and left arm; the impression was heat rash. An August 1975 record notes a rash of the entire body for two months; the clinical assessment was drug eruption versus viral exanthem versus contact dermatitis. An August 1975 record notes a resolving maculopapular eruption. A September 1975 record notes a body rash with a reported duration of one and a half months; the clinical impression was noted as possible maculopapular eruption. An October 1975 record notes a pruritic rash around the anterior waist for four days, assessed as tinea cruris. The December 1977 separation examination notes no skin conditions. The Veteran also testified regarding his in-service symptoms in the July 2018 Board hearing. The Veteran reported that he was treated for a rash in service that spread across his body. He also reported that his symptoms began shortly after handling barrels that he was told contained Agent Orange; the substance from these barrels leaked onto his person and he was unable to wash it off for approximately two hours. He also reported that since separation he has avoided sun exposure because it causes itchiness and/or a rash. The Board finds that the first and second elements of the service connection analysis are satisfied. Thus, the remaining question before the Board is whether there is a nexus with service or the service-connected disability. To this end, the Board has sought a competent medical opinion regarding whether there is a causal relationship between the current skin disability and the in-service symptoms multiple times throughout the pendency of this claim. Most recently, the Board remanded the claim in February 2021 due to a finding that the November 2020 VA medical opinion did not properly address the etiology of eczema or the benign neoplasm condition noted in 2014. Upon remand, the RO obtained a March 2021 medical opinion, which opined against a relationship to service. The VA examiner noted in detail the multiple STRs and post-service medical records noting skin signs or symptoms. The examiner stated that the medical record is silent for any treatment of a chronic rash prior to the diagnosis of eczema in March 2017. The in-service rash was not diagnosed as eczema and has none of the clinical features of eczema. It was noted as a maculo-papular rash. Furthermore, the medical history reported by the Veteran does not support a finding of a chronic eczematous rash since service. The Veteran stated on several occasions that the recurring rash since service occurs more in summer. As eczema is predominantly a loss of the skin's ability to act as a moisture barrier, the condition tends to flare or recur in the winter months, not the summer. The Board notes that the examiner's findings regarding the Veteran's statements about the condition during the summer is supported by the record. See March 2015 VA examination report (body rash occurs in the summer months in the heat and exposure to sun); September 2016 VA Form 9 (hot and humid weather worsens the skin condition). The March 2021 medical opinion also noted the Veteran's testimony that he handled barrels and was possibly exposed to Agent Orange and developed contact dermatitis, which was listed in the STRs as one of the differential diagnoses. As noted below, herbicide exposure has not been conceded. However, the research does not support an etiological relationship between Agent Orange exposure or contact dermatitis and the development of eczema. The examiner also noted a benign skin lesion removed from his chest in June 2014 and cited the pathology report noting a keloid scar with an infundibular cyst and overlying seborrheic keratosis. This is a common skin condition with no etiological relationship to the maculo-papular rash during service. The examiner also noted a benign skin lesion removed from his forehead in October 2014; this was diagnosed as a benign squamous papilloma, which is caused by the human papillomavirus and is also a common skin condition with no etiological relationship to the maculo-papular rash during service. The medical research does not support an etiological relationship between benign squamous papillomas and contended Agent Orange exposure or contact dermatitis. The Board acknowledges the Veteran's and the Veteran's representative's contentions that he has had chloracne and that his current skin disability is due to herbicide agent exposure in service. See July 2018 Board hearing; see also September 2016 VA Form 9 (reporting a rash lasting more than 40 years that occurred within days of handling barrels of Agent Orange). However, the Board has previously found that there is no competent evidence that the Veteran was exposed to herbicide agents in service. See August 2018 Board decision; see also February 2015 administrative decision (formal finding of the unavailability to verify exposure to Agent Orange). Moreover, the post-service medical treatment records and VA examination reports do not show that the Veteran has had a diagnosis of chloracne. See VA examination reports of March 2015, October 2019, and November 2020. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex. He does not have the requisite specialized knowledge, training, or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Thus, although the Board has carefully considered the lay contentions of record suggesting that his skin disability began during service, the Board ultimately affords the objective medical evidence of record, which weighs against finding such a connection, with greater probative weight than the lay opinion. Consequently, the Board affords more probative weight to the competent medical evidence of the March 2021 VA medical opinion. Here, the Board finds that the March 2021 VA medical opinion is based on an accurate medical and lay history as well as medical documentation provided in the claims file, to include the Veteran's STRs. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (noting that most of the probative value of a medical opinion comes from its reasoning). Additionally, the Board notes that neither the Veteran nor his representative have presented or identified any contrary medical opinion or treatment that supports his claim. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine cannot be applied. 38 U.S.C. § 5107(b); Gilbert v. Derwinksi, 1 Vet. App. 49, 53-56 (1990). Thus, service connection for a skin disability is not warranted. 2. Entitlement to service connection for a bilateral knee disability The Board finds that the Veteran has a bilateral knee disability that is related to in-service bilateral knee pain, thus warranting an award of service connection. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a). The record in this case is clear as to whether the Veteran has a bilateral knee disability. The post-service medical treatment records and VA examination reports reflect a diagnosis of bilateral patellofemoral pain syndrome, as well as right knee strain and left knee degenerative arthritis. See October 2019 VA examination; December 2020 VA examination. Thus, the first element of service connection, the existence of a current disability, is satisfied. Concerning the in-service event, illness, or injury, the Veteran's STRs show complaints of bilateral knee symptoms. An undated record notes very mild possible right knee chondromalacia patellae. A June 1975 record notes complaints of right knee pain following a kick; the clinical impression was noted as torn cartilage. A July 1975 record notes complaints of left knee giving out due to physical stress, and that the problem has lasted seven months following deep knee bends. The clinical impression was noted as torn cartilage. An October 1975 record notes a complaint of left knee pain that lasted 10 months. The Veteran testified during the July 2018 Board hearing that his knee pain began in service and never completely abated; long marches or runs during service exacerbated it. He reported that the symptoms continue to worsen over the years. Moreover, following separation, his left knee experienced frequent buckling. The Veteran also told that the October 2019 and November 2020 VA examiners that the onset of the pain was in service. The Board finds that the Veteran has provided credible and competent testimony regarding the symptoms of and treatment for his bilateral knee disability both during and following service. Based on the first two elements of service connection being satisfied, the Board sought a competent medical opinion regarding whether there is a causal relationship between the current disability and the in-service symptoms multiple times throughout the pendency of this claim. The Board finds that none of the opinions of record adequately address the Veteran's lay statements or the medical evidence of record. Most recently, the Board remanded the claim in February 2021 due to a finding that the November 2020 VA medical opinion is conclusory. Upon remand, the RO obtained a March 2021 medical opinion, which opined against a relationship to service, based in part on a lack of documentation in the years following service. This is an inadequate bases to deny service connection, especially given that the examiner did not address the Veteran's lay statements regarding his in-service symptoms or his symptoms since separation from service. The opinion is therefore not probative to the issue. However, the Board does not find another medical opinion need be obtained. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In conclusion, the Board finds that the evidence is at least in equipoise as to whether the Veteran's bilateral knee disability, which is currently diagnosed as bilateral knee patellofemoral pain syndrome, as well as right knee strain and left knee degenerative arthritis, had its onset during active service. Accordingly, the Board must resolve reasonable doubt in the Veteran's favor and finds that service connection for a bilateral knee disability is warranted. 38 U.S.C. § 5107 (b); 39 C.F.R § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Nathaniel J. Doan Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Minaya, 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.