Citation Nr: 21030600 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 12-16 535A DATE: May 19, 2021 ORDER Service connection for a skin disorder, to include psoriasis, is denied. FINDING OF FACT The weight of the evidence fails to show that it is at least as likely as not that the Veteran's skin disorder was incurred in, caused by, or otherwise is etiologically related to his active service, to include as a result of his presumptive exposure to herbicide agents, or etiologically related to his service connected heart and/or back disabilities. CONCLUSION OF LAW The criteria for service connection for a skin disorder have not been met. 38 U.S.C. §§ 1110, 1116; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the Army from November 1969 to September 1971, to include service in the Republican of Vietnam from May 1970 to April 1971. The Veteran filed a service connection claim in September 2009. He died in August 2012. The Appellant, the Veteran's surviving spouse, was substituted as the Appellant in this case in May 2013. The issue has been before the Board several times before. Most recently, in September 2020, the Board remanded the issue again for an additional VA opinion as to whether the Veteran's skin disability was secondary to his service-connected coronary arteriosclerosis. Such development has since been completed and the Board is satisfied that there has been substantial compliance with the remand directives. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R.§ 3.303. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service (nexus). Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Further, service connection may also be established on a secondary basis for a disability which is proximately due to, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310(a). In addition, service connection can be established based on herbicide exposure. 38 C.F.R. § 3.307(a)(6). A veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam is presumed to have been exposed to herbicides and the veteran is entitled to a presumption of service connection for certain diseases listed under 38 C.F.R. § 3.309(e). At the outset, the Board recognizes the Veteran's honorable service in the Republic of Vietnam from May 1970 to April 1971. As a result of this service, he is presumed to have been exposed to herbicide agents, such as Agent Orange, in service. See 38 C.F.R. § 3.307 (a)(6). As discussed below, the Veteran's skin disorder is not a disease listed under 38 C.F.R. § 3.309(e), as such, service connection cannot be established on a presumptive bases, meaning that the appellant must proffer direct evidence of how the Veteran's skin condition was the result of his military service, to include any herbicide exposure therein. Direct Service Connection The appellant is seeking service connection for Veteran's skin disorder, to include psoriasis, which she contends was the result of his Agent Orange exposure in Vietnam. In Veteran's September 2009 claim for benefits, Veteran indicated that his skin disorder began in 1989. In a November 2009 Statement in Support Claim, Veteran indicated that he did not complain of dry skin in Vietnam because he did not believe it was anything more than regular dry skin. He indicated that he sought private treatment within a few years of discharge. In his February 2010 Notice of Disagreement (NOD), however, Veteran indicated that he noticed skin pigmentation during service, while still in Vietnam, but did not report this at his separation physical and instead saw a private physician after discharge. The service treatment records (STRs) document no manifestations, to include initial signs, symptoms, complaints, diagnoses, or treatment, that may be associated with a skin disorder other than a groin rash in February 1970. The Veteran's separation physical showed normal skin condition. On his report of medical history in conjunction with the separation physical, the Veteran denied any skin disease, while reporting other health issues such as back trouble. Notably, Veteran applied for and received VA benefits for a service connected back condition in 1971 but he did not apply for service connection for a skin disorder at that time. This is not dispositive of the issue, but favor the suggestion that he did not have a skin condition at separation. A November 2013 VA Medical opinion concluded that Veteran's skin disease was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner indicated that after review of the available records, he was unable to find any documentation of skin problems. An addendum was obtained from this examiner in January 2014. After additional review of the file, the examiner indicated that Veteran received treatment for a groin rash during service in 1970 as well as post-service treatment outside the VA for several skin conditions, mostly growths. This examiner opined that the in-service groin dermatitis was less likely than not (less than 50 percent probability) to be related to his later skin conditions because there was not a mention of a specific diagnosis of skin disease in the STRs and the later skin condition appeared not to be related to Veteran's in-service groin rash. A December 2014 VA opinion, from the same examiner, concluded that all skin conditions mentioned, including skin growths and hand dermatitis were less likely than not (less than 50 percent probability) related to military service. The examiner opined that there is no likely connection between a dermatitis in the groin and the other conditions. A December 2015 VA opinion concluded that the Veteran's skin condition as noted in his medical file was not related to or aggravated by his presumed Agent Orange exposure. The examiner explained that there is no indication of an Agent Orange condition that involves skin growths or causes dermatitis to the groin and hands. The examiner indicated that the only skin condition related to herbicide exposure was chloracne, which the Veteran did not have. A June 2020 VA opinion reached the same conclusion as the December 2015. The Veteran's private medical records show that he was treated for lesions on his neck, face, chest, and upper thighs over a period from 1990 to 2004. The first report of private treatment for a skin disorder occurred in 1990, approximately 19 years after his discharge from service. VA treatment records show that in February 2008, the Veteran underwent an Agent Orange examination, which noted dry scaling with psoriasis on both hands, and multiple cherry angiomata but no other significant lesions at the time. VA treatment records in July 2009 indicate a medical history of psoriasis. August 2009 records show a referral to dermatology for evaluation of hyperkeratinized lesions on legs. During this appointment, Veteran requested an evaluation of white spots on his feet which he reported were present for a couple of years and complained of dryness of right hand and lower legs present for many years (over 10 years in about 1999). This is the earliest VA treatment record that indicating that the Veteran had a skin condition, which is approximately 30 years after he separated from his service. The Board finds that evidence is insufficient to show that the Veteran had a skin condition occurred during or was otherwise caused by his active service, to include his presumed exposure to herbicide agents. First, while the Veteran indicated in his February 2010 NOD that he noticed skin pigmentation changes and dry skin while service in Vietnam and STRs show that the Veteran was seen once in 1970 for rash in groin area, records show that it is as likely as not (50 percent or more probability) that the Veteran's skin problem was resolved given that the separation physical showed normal skin conditions and the Veteran denied any skin disease at his report of medical history in conjunction with the separation physical while reporting other health issues such as back trouble. In addition, the Veteran applied for service connection for his back condition in 1971 (within a month after he separated from service), but he did not apply for service connection for any skin disorder at that time. While the Veteran contented in his February 2010 Notice of Disagreement (NOD), that he noticed skin pigmentation during service while still in Vietnam, he did not report this at his separation physical and instead saw a private physician after discharge. However, the private treatment records that have been obtained show that the first report of a skin disorder occurred in 1990, approximately 19 years after his discharge from service. VA treatment records in August 2009 documented Veteran's report of dryness of right hand and lower legs present for many years (over 10 years in about 1999), which is approximately 30 years after he separated from his service. In addition, the January 2014 VA medical examiner concluded that the groin dermatitis treated during service was less likely than not (less than 50 percent probability) related to his later skin conditions. The December 2014 VA examiner concluded that all skin conditions mentioned by the post-service records, including skin growths and hand dermatitis were less likely than not (less than 50 percent probability) related to military service. The December 2015 VA examiner opined that the Veteran's skin condition as noted in his medical file was not related to or aggravated by Agent Orange exposure. The June 2020 VA examiner again opined that the Veteran's skin condition (to include skin growths or causes dermatitis to the groin and hands) was less likely than not (less than 50 percent probability) due to Agent Orange exposure. The VA examiners opinions were rendered after review of the Veteran's files, including STRs, and supported by sound rationales and have not been contradicted or undermined by any other medical opinion. In fact, the VA opinions are consistent with a study by the National Academy of Sciences (NAS), which shows "insufficient evidence of association" between herbicide exposure and skin cancer and chronic skin conditions (to include skin infections and skin pigmentation changes). See Nat'l Acad. of Sci., Inst. of Med., Veterans & Agent Orange: Update 2018 (the 11th edition). As such, these VA opinions will be given great probative value. Of note, while the Veteran was diagnosed and treated for various skin conditions, the records do not show that he was ever diagnosed or treated for chloracne, a skin disease that according to a study by the National Academy of Sciences (NAS), has "sufficient evidence of association" with herbicide exposure. See Nat'l Acad. of Sci., Inst. of Med., Veterans & Agent Orange: Update 2018 (the 11th edition). Accordingly, the Appellant's claim for direct service connection for Veteran's skin disorder is denied. Secondary Service Connection The Veteran/Appellant also suggested that his skin disease may have been secondary to his service-connected heart disease and/or back disability. A December 2015 VA opinion concluded that neither the Veteran's service-connected ischemic heart disease nor his service connected low back condition caused or aggravated his skin condition. The examiner explained that there was no medical evidence to support such a connection. In addition, as to the effect of the Veteran's medications for service connected disabilities, the examiner opined that it would have been noted that he had a medication type rash caused by medications, and he would have been treated to prevent any type of medication induced allergic reaction including and not limited to death. In a June 2020 VA opinion it was concluded that the Veteran's skin disorder was less likely than not (less than 50 percent probability) to be proximately due to or the result of the Veteran's service connected lumbar spine degenerative changes. The examiner opined that lumbar spine degenerative changes did not cause skin conditions. A November 2020 VA opinion concluded that Veteran's skin condition was less likely than not (less than 50 percent probability) due to Veteran's service-connected coronary arteriosclerosis. The examiner noted that review of the medical literature did not reveal evidence that coronary arteriosclerosis may cause the skin disorder of psoriasis. In fact, the examiner indicated that the reverse is more likely to be true: that skin disease may cause heart disease, specifically arrhythmias. The examiner quoted a study from www.medscape.com, which concluded that "psoriatic arthritis carries a higher risk of arrhythmia. People who have severe forms of the skin disease and are under age 60 are more likely to develop heart disease, according to findings published in the American Journal of Cardiology. Psoriasis can mean an increased risk of heart problems." The VA examiners opinions were rendered after a review of the Veteran's claims file, supported by sound rationales, and have not be contradicted or undermined by any other medical opinion. As such, these VA opinions will be given great probative value. While the Veteran and the Appellant believed that his skin disorder was related to his service connected heart and/or back disabilities, they have not been shown to have the medical training and/or expertise to provide a complex medical opinion as to the etiology of such a disability. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As such, their opinions are insufficient to provide the requisite nexus in this case. For that reason, several VA medical opinions were obtained, but as discussed above, these opinions were against the claim. Accordingly, service connection for a skin disorder is not warranted on a secondary basis. In sum, as the evidence does not support service connection based on presumptive, direct, or secondary bases, service connection for a skin disorder is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jennifer M. Narvaez, 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.