Citation Nr: 21029747 Decision Date: 05/14/21 Archive Date: 05/14/21 DOCKET NO. 13-22 459 DATE: May 14, 2021 REMANDED Entitlement to service connection for a skin disorder, claimed as a recurrent skin rash, is remanded. REASONS FOR REMAND The Veteran had active duty from April 1968 to April 1970, to include service in the Republic of Vietnam from May 1969 to April 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2016, the Veteran testified at a hearing conducted before a Veterans Law Judge who has since retired from the Board. A transcript of that hearing is of record. In February 2018, the Veteran was sent a letter offering him the opportunity to testify at a new hearing before a Veterans Law Judge who would participate in the decision. See 38 U.S.C. § 7107(c); 38 C.F.R. § 20.707. The Veteran's attorney indicated that the Veteran did not further hearing in this matter in a March 2018 submission. Accordingly, the Board will consider the appeal based on the evidence of record. 38 U.S.C. § 7107(c); 38 C.F.R. § 20.707. This claim was previously before the Board in February 2019 and August 2020, when it was remanded for further development. 1. Skin Disorder The Veteran asserts that his skin disorder is due to his active service. In the alternative, the Veteran asserts that his claimed skin disorder is related to in-service herbicide exposure. As already alluded to, the Board previously remanded this claim in February 2019 for a needed medical examination an opinion. When, as here, VA obtains an examination and opinion in response to a claim, it must ensure the examination and opinion are adequate. A January 2020 opinion obtained on remand reflects the opinion of the examiner that it is less likely than not the Veteran has a skin rash causally related to his service. The examiner observed that the earliest reference of treatment found in the claims file for a skin rash was in 2005, many years after the Veteran's separation from service (which was in 1970). The examiner also found that the Veteran's seborrheic dermatitis and epidermal cysts dating back to 2005 are not associated with exposure to an herbicide agent. See Skin Diseases Disability Benefits Questionnaire (DBQ), December 18, 2019. Per the August 2020 Board remand, the Veteran underwent an examination to determine the nature the etiology of his skin disorder in March 2021. See Skin Diseases DBQ, March 11, 2021. The examiner confirmed a diagnosis of a skin disorder. Namely, the examiner reported that the Veteran experienced prurigo nodularis. The examiner then opined that the skin disorder was less likely as not related to the Veteran's active service. The examiner stated that the records did not indicate that the Veteran did not experience a skin disorder in active service, and the first skin complaints were recorded in the Veteran's medical records in the 2000s. The March 2021 examiner failed to provide an opinion as to whether the Veteran's skin disorder is related to herbicide agent exposure. And again, the examiner based the examination on an incorrect factual premise namely, that the first complaints of skin issues were noted in the 2000s. See Reonal v. Brown, 5 Vet. App. 460, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value). The Board is mindful that the Veteran's service treatment records are unremarkable for indication of a rash, that the Veteran denied a skin disease when separating from service, and that he had a normal skin evaluation for separation from service in April 1970. However, a review of his claims file also reveals the following evidence with regard to a skin rash or condition prior to the 2005 supposed initial onset noted by the examiner: pityriasis rosea on the chest (December 1970), comedones on the back (April 1971), a statement by the Veteran as to a constant rash since service (February 1973), a statement by the Veteran that he gets rash/hives on his arms and back (February 1998), a sebaceous cyst on the right arm for two to three years (April 1998), and no visible skin rash but a diagnosis of mild dermatitis due to dry skin upon report by Veteran that he has itchiness over both upper extremities (March 2002). In June 2005, a VA psychologist observed red dots on the Veteran's skin and noted that, because of such, it "appears that he has chloracne." Following his separation from active service, the Veteran was diagnosed with seborrheic dermatitis, epidermal cyst, hyperpigmentation, prurigo nodularis, intertrigo, and a psychologist noted that the Veteran might have chloracne. Based on the clinical records noting seemingly relevant complaints well before 2005, and the Veteran's statements made way back in 1973, the Board finds that supplemental medical comment is needed concerning this remaining claim. In sum, multiple medical opinions in this matter exist in the claims file, do not allow the Board to answer the basic questions whether the Veteran's claimed skin disorder is related to his active service, to include as due to herbicide agent exposure. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, forward the Veteran's record to a qualified medical professional such as a dermatologist for an opinion addressing the following regarding the Veteran's claimed skin disorder. The claims file must be reviewed by the examiner. A physical examination of the Veteran or telehealth examination is only required if deemed necessary by the clinician. The examiner should respond to the following questions: (A) Identify all skin disorder present at any time since August 2017. (B) For each skin disorder identified, please state whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any diagnosed skin disorder had its onset in service, or is etiologically related to the Veteran's active duty service, to include herbicide agent exposure. To assist in making this determination, please consider the pertinent evidence of record, including especially: a) the Veteran's denial of a skin disease upon separation in April 1970; b) his normal skin upon examination in April 1970 when seen for separation purposes; but also c) the December 1970 clinical finding of pityriasis rosea on the chest; d) the April 1971 VA examination noting comedones on the back; e) the Veteran's February 1973 statement as to a constant rash since service; f) his February 1998 statement that he gets rash/hives on his arms and back; g) a sebaceous cyst on the right arm with a reported onset of two to three years earlier; h) a March 2002 VA clinical record noting no visible skin rash but a diagnosis of mild dermatitis due to dry skin upon report by the Veteran that he has itchiness over both upper extremities; and i) the March 2005 VA psychologist's observation that, because of red dots on the Veteran's body, it "appears that he has chloracne." In rendering an opinion, the commenting clinician should consider whether the Veteran's various post-service diagnosed skin conditions (e.g., seborrheic dermatitis, epidermal cyst, hyperpigmentation, prurigo nodularis, intertrigo, and a psychologist noting that it appears the Veteran has chloracne) are a) self-limiting conditions, acute, and/or chronic; b) would reasonably have been noticed upon examination in April 1970, if present; and c) the locations of the Veteran's symptoms and rashes, etc., as they may relate to diagnosis or cause, if relevant. It is essential the examiner provide rationale for his/her responses, preferably citing to evidence in the file supporting conclusions and/or accepted medical authority. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Lech, 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.