Citation Nr: 21028651 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-38 394 DATE: May 11, 2021 ORDER Prior to August 10, 2018, a compensable rating for pseudofolliculitis barbae is denied. As of August 10, 2018, a rating higher than 30 percent for pseudofolliculitis barbae is denied. FINDINGS OF FACT 1. Prior to August 10, 2018, the Veteran's pseudofolliculitis barbae was not shown to have affected at least 5 percent of exposed areas or at least 5 percent of his entire body. This disability did not require systemic therapy. It did not manifest by scars or disfigurement of the head, face, or neck. 2. As of August 10, 2018, the Veteran's pseudofolliculitis barbae does not affect more than 40 percent of the entire body or more than 40 percent of exposed areas. This disability does not require systemic therapy. It does not manifest by scars or disfigurement of the head, face, or neck. CONCLUSIONS OF LAW 1. Prior to August 10, 2018, the criteria for a compensable rating for pseudofolliculitis barbae have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code (DC) 7813-7806. 2. As of August 10, 2018, the criteria for a rating higher than 30 percent for pseudofolliculitis barbae have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code (DC) 7813-7806. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1999 to March 2008 and from February 2014 to August 2014. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which, in relevant part, granted service connection for pseudofolliculitis barbae and assigned a noncompensable (0 percent) rating effective December 20, 2015. The Veteran appealed this initial rating with a March 2016 notice of disagreement. The RO issued a statement of the case in May 2016 and the Veteran perfected his appeal with a July 2016 VA Form 9. In a September 2018 rating decision during the pendency of this appeal, the RO granted an increased rating for pseudofolliculitis barbae, assigning a 30 percent rating effective August 10, 2018. Increased Rating An increased rating for pseudofolliculitis barbae The Veteran is seeking an increased rating for pseudofolliculitis barbae. As described above, this rating is currently staged. The Veteran's pseudofolliculitis barbae is rated under hyphenated diagnostic code 7813-7806. Hyphenated diagnostic codes are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, DC 7813 instructed to rate as disfigurement of the, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), or dermatitis (7806) depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7813. Here, the evidence of record demonstrates that the predominant disability is dermatitis. As detailed below, the Veteran's pseudofolliculitis barbae has not resulted in scarring or disfigurement but has manifested as papules. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 31, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824. As noted above, in this case the predominant disability is dermatitis. As an initial matter, the Board notes that the Veteran has an additional skin disability, tinea versicolor, that has been repeatedly found to be separate and distinct from his service-connected pseudofolliculitis barbae (PFB). Furthermore, tinea versicolor has not been found to be causally linked to the Veteran's active duty military service or to any service-connected disability. See e.g., October 2015 medial opinion. As such, to the extent that the resulting symptoms can be separated, the Board will only consider those symptoms attributable to PFB. Prior to August 10, 2018 The January 2016 VA skin diseases disability benefits questionnaire (DBQ) shows diagnoses of dermatitis and PFB. The Veteran treated his PFB with over-the counter anti-bump treatments and shaved with an electric razor. None of the Veteran's skin conditions caused scarring or disfigurement of the head, face, or neck. He did not have any benign or malignant skin neoplasms. He did not have any systemic manifestations due to any skin diseases. He had treated his PFB with topical medications (the over-the-counter treatments) constantly or near-constantly. He had not had any treatments or procedures other than systemic or topical medications in the prior 12 months for exfoliative dermatitis or papulosquamous disorders. He had not had any debilitating or non-debilitating episodes in the prior 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. Physical examination did not find any visible or other specific skin conditions. The Veteran did not have any benign or malignant neoplasm or metastases related to any skin condition. He did not have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any skin condition. His skin conditions did not impact his ability to work. He had areas on his back and chest that were consistent with post-inflammatory pigment alteration, but no active areas of dermatitis. He also had lesions of pseudofolliculitis barbae on the anterior and posterior neck that affected approximately 2 percent of the body surface area. VA treatment records from this period repeatedly found no new lesions, rashes, or changes in old lesions. Prior to August 10, 2018, the Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the pre-August 13, 2018, regulations because the Veteran's PFB does not more nearly approximate at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. Instead, his PFB is shown to affect approximately 2 percent of the body surface area and was treated with topical medications only. There is no associated scarring or disfigurement of the head, face, or neck. Likewise, prior to August 10, 2018, the Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the August 13, 2018, regulations because the Veteran's PFB does not more nearly approximate characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy required for a total duration of less than 6 weeks over the past 12- month period. Again, his PFB is shown to affect approximately 2 percent of the body surface area and was treated with topical medications only. Again, there is no associated scarring or disfigurement of the head, face, or neck. Thus, there is no basis to award a compensable rating for PFB during this period under either version of the rating criteria. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. However, he does not assert, and medical treatment records do not show, that the Veteran's disability more nearly approximates the criteria in the next higher rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a compensable rating for pseudofolliculitis barbae (PFB) prior to August 10, 2018. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. As of August 10, 2018 The August 23, 2018 skin DBQ shows the Veteran's reported of outbreaks in the beard area, hives, and itching. He treated the hives with oral medication (Benadryl) and the PFB with topical medication (nizoral cream). This treatment was constant or near-constant. He had not had any treatments or procedures in the past 12 months for any skin condition. Physical examination found dermatophytosis affected 20 to 40 percent of the total body area and from 5 to less than 20 percent of the exposed area. Specifically, his PFB manifested as papules on the face and back. He did not have any visible characteristics associated with his hives. The Veteran had not had a break in his antihistamines and first line treatment for chronic urticaria. None of the Veteran's skin conditions caused disfigurement of the head, face, or neck or scarring. He did not have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any skin condition. His skin conditions did not impact his ability to work. The October 2019 skin DBQ notes diagnoses of tinea versicolor and PFB. He reported current symptoms of razor bumps and, when tinea versicolor is present, intermittent itching. He treated his tinea versicolor with topical ketoconazole less than six weeks in the prior year. He had not had any treatments or procedures other than systemic or topical medications in the past 12 months for any skin condition. Physical examination found dermatophytosis affected none of the total body area and none of the exposed area. His PFB affected less than 5 percent of the total body area and less than 5 percent of the exposed area. At the time of this examination, the Veteran's PFB manifested as scattered small razor bumps and bear stubble mainly on the upper neck and chin. There was no visible tinea versicolor. The Veteran did not have any benign or malignant neoplasm or metastases related to any skin condition. His skin conditions did not cause disfigurement of the head, face, or neck or scarring. He did not have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any skin condition. His skin conditions did not impact his ability to work. In a September 2019 opinion, the examiner noted that PFB was, by definition, related to shaving. As the entire head was only 9 percent of the total body surface, he was not able to have 20 or 30 percent total body involvement with PFB. Additionally, to the extent that earlier examination had referred to urticaria, it was likely that this was an erroneous diagnosis made based on his tinea versicolor symptoms as urticaria was not described by the Veteran or seen on the current examination. VA treatment records from this period repeatedly found no new lesions, rashes, or changes in old lesions. As of August 10, 2018, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent under the pre-August 13, 2018, regulations because the Veteran's PFB does not more nearly approximate more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. The record does not show a sufficiently large affected area to warrant a higher rating. Instead, this disability affects less than 20 percent of the exposed area. Moreover, as explained in the September 2019 opinion, this disability is related to shaving and given that the beard area is only part of the head and the entire head is only 9 percent of the total body surface, rendering it impossible that this disability could affect 40 percent or more of the total body surface. The Veteran's PFB was treated with topical medications, not systemic therapy, much less constant or near-constant systemic therapy. Finally, there is no associated scarring or disfigurement of the head, face, or neck. Likewise, the Board finds that, as of August 10, 2018, the evidence is against the assignment of a rating higher than 30 percent under August 13, 2018, regulations because his PFB was not shown to affect more than 40 percent of the entire body or more than 40 percent of exposed areas. Again, the Veteran's PFB was treated with topical medications, not systemic therapy such as corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs It does not manifest by scars or disfigurement of the head, face, or neck. Thus, a rating higher than 30 percent for pseudofolliculitis barbae is not warranted under both versions of the diagnostic criteria during this period. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. However, he does not assert, and medical treatment records do not show, that the Veteran's disability more nearly approximates the criteria in the next higher rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. (Continued on the next page) In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim of a rating in excess of 30 percent for pseudofolliculitis barbae (PFB) as of August 10, 2018. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. ERIC MINE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Houbeck 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.